improving the value of high-end imaging
DESCRIPTION
For more information on Group Health's high-end imaging improvements and innovations like this, please go to www.ghinnovates.org.TRANSCRIPT
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
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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
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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)
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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%
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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.
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High End Imaging Variation in PC Across All Clinics
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Intra-Clinic Variation
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High End Imaging Variation in Specialty Across Service Lines
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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
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Feedback
Effectiveness: Variable effectiveness in controlled trials
Peer comparison > Aggregate
Active > Passive
Concurrent > Delayed
More effective with personal contact
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Robert Karl, Jr., MDGroup Health Physicians
High End Imaging
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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
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Integration of Clinical Decision Support into Epic
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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
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Virtual Consults
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Virtual Consult Documentation
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Group Practice Ordering Rate
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Primary Care Ordering Rates
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Specialty Care Ordering Rates
Managing Advanced Imaging At The Everett Clinic
Kelly Weaver, MD
Advanced Imaging Center
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Lumbar Spine Imaging
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EMR Ordering Screen
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EMR Ordering Screen
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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
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# CT and MRI in 2009Family Practice
800
700
600
500
400
300
200
100
0
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Complete The Message
What providers can’t do
VS.
What providers should do
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2010: The High Road
• Communication . . .–Study Duplication
–Radiation Exposure
–Conservative Care First
–Cost Of Care• My $400.00 Normal Shoulder MRI
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2010: The Low Road
• “Weaver” Graphs
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# CT and MRI in 2009Family Practice
800
700
600
500
400
300
200
100
0
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# CT and MRI per 1000 Visits FP in 2009
120
100
80
60
40
20
0
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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
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Q4 2010 Results Compared to 2006
37
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Take Home – “Engagement”
• Evidence Based Medicine – Good!
• Education – Good!
• Guilt – Better!
• Ego – Best!
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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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