improving the value of high-end imaging

1 | Group Health Solutions for Transforming Care

Matt Handley, MD and Robert Karl, Jr., MDGroup Health Physicians

Kelly Weaver, MDThe Everett Clinic

Improving the Value of High-End Imaging: Engaging Providers With Feedback

Value Matters

While administrative efforts can achieve some decreases in utilization, they can decrease both appropriate and inappropriate care

We cannot improve the value of the care we deliver without clinicians making different decisions with patients.

The decisions clinicians make drive roughly 84% of the costs of care

Case for Change

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)

Imaging is not without risk – 1-2% of the cancer in the US is thought to be iatrogenic

Costs associated with imaging are rising rapidly (for purchasers, payors and patients)

Why High End Imaging Matters Clinically

There are two main risks to High End Imaging:

Harm from Ionizing Radiation 1-2% of the cancers in the US now

caused by ionizing radiation CTs done in 2007 will result in 29,000

cancers

Harm from following and investigating “Incidentalomas” Up to 40% of studies have incidental

findings, follow up recommended in 10 – 20%

Clinical Variation as a Fractal

A fractal is "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.

High End Imaging Variation in PC Across All Clinics

Intra-Clinic Variation

High End Imaging Variation in Specialty Across Service Lines

The Toolkit for Changing Practice

Engagement - case for change, alignment of values, involvement in generating solutions

Tactics Large and Small group CME Feedback Academic Detailing Clinical Opinion leaders Clinical Decision Support Patient Specific decision support Patient centered strategies Clinical process redesign - workflow Administrative/regulatory activities

Feedback

Effectiveness: Variable effectiveness in controlled trials

Peer comparison > Aggregate

Active > Passive

Concurrent > Delayed

More effective with personal contact

Robert Karl, Jr., MDGroup Health Physicians

High End Imaging

The GHC Story

Case for change—Safety, Decision Support, Value

Focus on Clinical Decision Support

Embed in EMR Clinical tool isn’t perfect

“necessary but insufficient”

One part of the intervention

Easy access to specialty consultation

Feedback - active, peer comparison, quarterly, transparent

Integration of Clinical Decision Support into Epic

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

Virtual Consults

Virtual Consult Documentation

Group Practice Ordering Rate

Primary Care Ordering Rates

Specialty Care Ordering Rates

Managing Advanced Imaging At The Everett Clinic

Kelly Weaver, MD

Advanced Imaging Center

Lumbar Spine Imaging

EMR Ordering Screen

January 1, 2010

• Criteria “Mandatory”

MRI Cervical Spine CT Chest

MRI Thoracic Spine CT Abdomen & Pelvis

MRI Lumbar Spine CT Sinus

MRI Knee MRI Shoulder

Cardiac Nuclear

# CT and MRI in 2009Family Practice

Complete The Message

What providers can’t do

What providers should do

2010: The High Road

• Communication . . .–Study Duplication

–Radiation Exposure

–Conservative Care First

–Cost Of Care• My $400.00 Normal Shoulder MRI

2010: The Low Road

• “Weaver” Graphs

# CT and MRI in 2009Family Practice

# CT and MRI per 1000 Visits FP in 2009

July 1, 2010

• Criteria “Mandatory”MRI Cervical Spine CT Chest

MRI Thoracic Spine CT Abdomen & Pelvis

MRI Lumbar Spine CT Sinus

MRI Knee MRI Shoulder

Cardiac Nuclear

MRI Brain CT Brain

MRI Elbow MRI Ankle

MRI Wrist MRI Hip

Q4 2010 Results Compared to 2006

Take Home – “Engagement”

• Evidence Based Medicine – Good!

• Education – Good!

• Guilt – Better!

• Ego – Best!

Learning Together

While we are making progress in the “technical” aspects of change, we are just starting the “adaptive” aspects of change

How will we continue to improve? Transparency of performance Collegial conversations Change of Paradigm

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?

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