Decision support tool saves time, money, but health plans resist

There's an alternative to radiology benefit managers that can cut down on labor hours, save money, and ensure patients receive the right imaging test the first time. Yet clinical physician order entry with evidence-based decision support, sometimes called e-ordering, is being used in only a few places because healthcare plans are resistant to change, despite the proven benefits.

While there are computer physician order entry systems in circulation, most often associated with a RIS, the most interesting and important element of these systems is decision support, according to several experts. Decision support circumvents the need for radiology benefit managers by electronically obtaining prior authorization for an exam.

As Diagnostic Imaging previously reported, Massachusetts General Hospital was the first to create an order/support system. Staff at the hospital term their tool “radiology order entry and decision support” and they created the system mostly to enable electronic ordering of exams, but also to help the referring physicians figure out which exam to order in the first place (see “Hospital finds tough road to ROE worth the effort,” February 2007, page s-9).

WHAT THEY DO

The advantage of order/support systems is they help manage and automate complex workflows involving the ordering doctor, clinic staff, the patient, radiology scheduling personnel, technologists, radiology billing personnel, and, eventually, radiologists, said Dr. Chris Sistrom, vice chair of radiology at the University of Florida and visiting research fellow at MGH.

“This is especially true when there are preauthorization regimens from payers and increasing emphasis on compliance with various quality and fiscal requirements,” he said. “Adopting computerized order entry and fulfillment is a great opportunity for imaging providers to clean up and modernize their whole business operation.”

The decision support piece of order/support systems requires the referring physician to enter clinical information like the patient's symptoms, known diagnoses, age, and other factors. The information is processed through an algorithm that relies on the American College of Radiology's Appropriateness Criteria to create a decision support score. A high score means the test is appropriate and necessary. A low score asks the doctor to rethink the exam but allows him or her to order the test anyway. Radiation dose and duplicate exam alerts are also built into the system.

“Radiology order entry and decision support allows doctors to capture finely grained, clinically meaningful data regarding patterns of imaging utilization,” said Dr. Jeffrey Weilburg, associate medical director of MGH's Physician Organization. “Sharing these data with users allows collaboration between users and radiologists, and permits control of utilization in the setting of genuine quality improvement.”

Quality improvement is achieved because there are no more written or verbal orders for imaging tests to be misunderstood or performed on the wrong patient, Sistrom said. Also, indications for doing the test are captured in a structured and meaningful form. Order/support systems aid in deciding on the right protocol and thus in interpreting the images.

Commercially available versions of order/support systems include Nuance Healthcare Solutions' RadPort and Medicalis' Decision Support Server.

WHY THEY MATTER

Radiologists should care about order/support because the systems are a natural extension of their traditional consulting role, said Liz Quam, executive director of the Center for Diagnostic Imaging (CDI), based in Minneapolis.

“If you track back to how radiologists are trained, it is to consult with treating clinicians and help them figure out what is the appropriate scan,” she said. “This is just an electronic, or faster, way of doing it.”

Radiologists can also use order/support systems as a way to document the appropriateness of care. It provides an electronic record of the care offered and whether it was appropriate for the patient's condition, she said.

“We're trying to narrow it down to do the right test the first time for the patient,” said Scott Coswill, senior product manager for the healthcare diagnostics division at Nuance.

Order/support systems reduce the chance of doing a head CT that comes back as inconclusive-because it was an inappropriate test-and now has to be followed up with a head MR, he said.

“In a situation like that, the insurance company has to pay twice and the provider has to order two tests. The patient has two copays, has to take two days off work, and has two deductibles,” he said.

With order/support systems the situation doesn't arise; the system is built to avoid that type of incident.

“Now we don't have to sit on hold for forever and a day,” said Lori Loverink, scheduling supervisor for Suburban Radiologic Consultants' Coon Rapids, MN, site and a RadPort customer.

Workflow is much faster using RadPort, she said, because the insurance companies allow preauthorization and precertification when they do. The reason payers have granted preauthorization, though, is because of decision support.

“We can't just call and say ‘low back pain' anymore,” she said. “RadPort has required us to ask more questions and get more information from our referring clinics and physicians.”

Now physicians have to detail symptoms, and how long the patient has had the pain.

With decision support the entire preauthorization process is transparent, which is not the case with radiology benefit managers. The overarching gripe with RBMs is the secrecy of their approval process. The rules and algorithms they use to make determinations about what studies to deny are proprietary.

“This is because the ‘rules engine' about what to authorize is the essence of these firms' intellectual property,” Sistrom said.

The public websites of some RBMs contain evidence-based guidelines and some refer to ACR's Appropriateness Criteria.

“At the end of the day, however, there is a carefully guarded and continuously refined collection of business logic that workers at the RBM call centers use as ‘scripts' to guide their determinations,” he said.

When a physician or office staff contacts an RBM, the reasons for acquiescing to or declining an exam are proprietary because if people knew what the criteria were, they would have no need for an RBM.

The physician has to call the office and jump through a series of hoops, answering very specific questions. Oftentimes the clerk on the other end of the line will say, “No,” and not give a reason why. Nothing will happen and the entire process comes to a halt.

“You can't do anything and it's quite difficult to get imaging the same day,” said Dr. Steven Pollei, the medical director of CDI in Federal Way and Lakewood, WA. “The e-ordering tools allow for much more rapid data entry and decision feedback.”

The decision feedback lets the referring clinician and radiologist see the criteria for ordering a test, he said, making the process is transparent. Instead of being subjected to guesswork, the radiologist and referring physician can clearly see why a test was approved or not approved. Plus, since the system is electronic, the entire process moves much more quickly.

All the time spent on the phone adds up. By switching to order/support systems, CDI saved 303 labor hours per month, according to Dr. Barry A. Bershow, the medical director of quality and informatics at Fairview Health Services in Minneapolis.

Fairview Health Services is a Minnesota-based integrated healthcare network of preventive, primary, specialty, acute, long-term, and home care services. It includes 10 hospitals and several hundred physician partners.

Bershow estimates calling an RBM takes at least 10 minutes per order. At 1850 orders per month, that adds up to 308 hours. Order/support systems, on the other hand, take 10 seconds per order, or only five hours per month.

Order/support systems also ensure the right test is done the first time. While it's hard to tell if there was a downswing in CT versus MR, Fairview Health Services found when using order/support systems the number of scans overall for Medicare patients dropped by approximately 12.5%.

An MGH study, published in the April issue of Radiology, showed a significant decrease in volume growth for CT (0.25%), MR (1.2%), and ultrasound (1.3%) after the hospital implemented ROE-DS.

In Minnesota there wasn't a change in overall volume so much as a rearrangement by modality, according to Quam. Patients still went to the same center, but they just may not have received the same test as they would have before order/support system implementation.

There aren't many data available on the effects of order/support systems because so few places currently use it: MGH and facilities across Minnesota. Legislation passed in Washington state (HB 2105) follows Minnesota in implementing a statewide initiative to use order/support systems.

With an RBM or order/support system there will likely be a decrease over time in the total number of imaging studies performed, Pollei said. Anecdotally, a big change with order/support systems comes in the timing of when tests get ordered. Switching to a decision support tool introduces a time lag for referring clinicians who tend to order images early, he said. So patients don't get scanned at the same point in their illness; they get scanned when the decision support tool says they should be scanned.

“The big thing you'll notice on the front end is a change in timing. So you may notice that you have a month or two when you have less imaging just because you're getting into the timing of the procedures,” he said.

For instance, a patient may come in with low back pain. Guidelines say the patient should be treated conservatively for four to six weeks. With an RBM a patient absolutely cannot get imaged until their guidelines say yes. With decision support there is more flexibility. A patient can be imaged earlier if there are certain confounding factors like significant trauma.

WHY IT'S NOT MORE WIDESPREAD

The slow adoption of order/support systems isn't because of radiologists or referring physicians but because of health plans, Quam said.

“It's the health plan that doesn't want to do something different than what they're already doing,” she said.

Despite proving order/support systems save money and ensure the right test is ordered the first time, health plans are hesitant to change.

“Sometimes it feels like we're talking to a brick wall,” Quam said. “They've already gotten something put into place and they don't want to change. They don't want to hear it, even though order/support systems are more efficient.”

Eventually, though, order/support systems will pick up speed and more people will adopt it, Pollei said.

“It makes more sense than RBMs,” he said. “RBMs are really old-school technology and really old ideas.”

Order/support systems are more educational and more sustainable because the guidelines can be changed and updated, Quam said.

“This is something that can still be in place 20 years from now,” she said.