Quality

Creating Practical Value in Practice (of Radiology)

dondennison Radiology , , , ,

There is a lot written these days about the shift from volume-based to value-based in Radiology (and other medical specialties).

The thing is: volume is real easy to measure. And what gets measured, gets managed.

So, how do we measure value?

One can measure the time it takes to complete the report, sign it, and make it available to physicians and other members of the care team. Radiology practitioners call this Turnaround Time (or TAT). This is pretty easy to do.

We could try to measure whether the report is correct. In other words, is what the Radiologist concludes actually what is wrong (or not wrong) with the patient? This can be harder to measure, as it may take a lot of work to correlate many different data points, or a lengthy period of time for proof to be found.

There are a couple of activities that Radiologists, and other people working in the department, can do to improve the perceived value of Radiology.

In this article, a number of suggestions are made as to how to increase the visibility of Radiologists, as well as improve relationships and trust among other physicians and even patients.

And this WSJ article focuses on simply improving the clarity of the report by improving the language and writing skills of Radiologist. Seems obvious as to the value this would provide, when you read it, but how many Radiologists routinely attend training on how to communicate better?

While improving how Radiologists interact with the outside world—whether through better interactions or better writing—will help the Radiologist’s career, one would hope that it would also improve care. Better communication certainly couldn’t hurt.

Article – Who is the better radiologist? Hint, it’s not that easy.

dondennison Radiology , ,

I really enjoyed this article. It gets into the specifics of what we could mean by quality of Radiology reading.

I think it gets to the crux of the problem in any domain when quality is desired—a trade off is necessary. It may be cost, or it may be the experience of the user, but it will be somewhere.

Let’s use a similar evaluation in software development.

Coders that are fast are lauded as innovative and bright and creative, until their barely-tested and unscalable application fails in operations, or a security hole results in a data breach. These folks are often called “hackers” (but generally in a positive way).

The more thorough developer is criticized for taking too long and keeping the application in the lab (instead of the “real world”) for too long. They spend significantly more time in the design and testing and documentation areas, so to outsiders, they are slow. Their products take more time (missing some early opportunities seized by hackers), but the applications are much more reliable and supportable in operations. They are professional software developers.

As someone that has managed R&D teams before, you always want both behaviors (and results), but as the article posits, you often cannot have both. You certainly shouldn’t expect to get both.

I often say: Decisions are easy (I decide I want innovation and reliability, and I want it fast), but Choices are hard. I value people that can make choices, and live with them, much more than so called “decision makers”.

Article – CDC on EHR errors: Enough’s enough

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In this article, the CDC has issued a warning on the issues of user interface design when presenting patient information in EHRs.

As the examples in the article illustrate, having information in digital form is not enough. It needs to be presented in an effective way to ensure comprehension. After the current wave of information digitization and consolidation (moving information from disparate, departmental clinical information systems into a single large enterprise system), the next wave of effort needs to be on privacy/security, accessibility/reliability, and usability, or the incredibly high potential gains will not be realized.

Users need to trust the system, it needs to be there when they need it (wherever that is), and they have to want to use it.

P.S. Here is an infographic on EHR adoption.

Revenue Revolution in Radiology

dondennison Financials , , , , , , , ,

I have been reading a lot recently about trends in healthcare and imaging around costs and revenues. There seems to be a perfect storm of changes in the market that will have a fundamental impact on diagnostic imaging service providers. I find this topic interesting because, unless you understand how the money is moving, you won’t understand why things are happening. Here is a summary of what I have discovered.

Medicare Reimbursement Cuts

This one is obvious. If you lower the amount of money paid for something, your revenues will go down (unless volume goes up proportionally). Here is an infographic from MITA on the cuts made since 2006.

Fewer Medical Imaging Exams being Ordered

Here is an article from MITA on the decline of the total number of CT exams being done in the U.S. Here is another one citing data published by the American College of Radiology (ACR). It states: “…physicians are calling for less, not more, imaging tests.” This shows a measurable reduction in the volume of exams performed in the U.S. And here is an article indicating a steady decrease in imaging studies being ordered for patients in the ED, following a steady increase up to 2007.

Image Sharing

The sharing of patients’ clinical records across facilities is a key part of Accountable Care, and is generally a good thing for patient care. So is sharing imaging records. With reliable options now available on the market, sites within a local referral area are rapidly launching or signing up to services to share images. The clinical benefits of comparing new imaging exams with priors are well understood, but this practice will often result in avoiding the need to perform a repeat exam. This benefits the patient (less radiation and anxiety and delay), and the operations of the receiving organization (less schedule disruption, less costs due to CD importation). The other impact, of course, is that the receiving organization loses some revenue from that avoided repeat exam. This will result in a reduction in volume of exams performed.

Adoption of Clinical Decision Support

Starting on January 1, 2017, imaging exams will require the use of Clinical Decision Support (CDS) to ensure that physicians are following Appropriate Use Criteria (AUC). In addition to clinical evidence, factors such as relative radiation level and cost of the exam are used to determine what is appropriate. All things being equal, the lower cost exam is likely to be recommended. The adoption of CDS may result in a reduction in volume of exams performed, or a recommendation to a lower cost (profit) exam.

Preauthorization Requirements

In some insurance plans, preauthorization is required before certain exam types can be ordered (even when CDS is used, in some cases). This may require a consultation with a radiologist or Radiology Benefits Management (RBM) company. Here is an article from 2011 on the use of preauthorization and CDS. The larger the burden on the ordering physician, the less likely they are to order the exam, which may result in a reduction in volume of exams performed, or a recommendation to a lower cost (profit) exam.

Patient Steerage

Last year, I did a blog post on an article on the trend of “patient steerage”. The original article is here. Essentially, patient steerage is when a payer incents a patient to use a provider that offers the imaging service at a lower cost. If a service provider is not price competitive, this will result in a reduction in volume of exams performed.

The Castlight Effect

This company received a lot of attention because of the size of its IPO, but it is also notable for what they actually do. As this article explains, they provide healthcare provider cost information for a range of healthcare services to employee health plans. The intent being that, given the choice, consumers will choose lower cost options. This is very likely to happen when the patient has a significant co-pay (e.g. 20%) and they will personally benefit from lower cost options. If a service provider is not price competitive, this will result in a reduction in volume of exams performed.

Wait, but what about Quality?

With all the talk about the shift of reimbursement from volume of procedures to quality or outcomes, I found this tweet on Castlight interesting… Castlight Tweet If we shift away from volume incentives/payment, reduce the prices paid (through policy or competition), but don’t recognize quality, the service of diagnostic imaging has been commoditized, and I don’t think that this will benefit patients, in the end.

Consolidation

I have heard a couple of opinions that believe that the strong trend of consolidation among healthcare providers will allow the largest of providers to dictate terms and pricing to payers. As it was explained to me, it works like this: The big, well-known healthcare provider, which has bought up many of the facilities in the area, tells the insurance payers, ‘If you don’t give me preferential pricing for my services, I won’t accept your insurance plan at my facilities’. If the healthcare provider is big enough and well respected, the insurance provider will have a tough time selling insurance plans to companies and individuals when the buyer learns that they can’t go to the big provider. This is called leverage. If this is true (and I think that it is), this will result in isolated areas of reimbursement stabilization or even increases. Here is an article talking about what the impact of provider consolidation means to private payers. It cites a steady increase in the number of physicians becoming employees of hospitals (vs. independent private practices)…

“…the number of doctors employed by hospitals increased to over 120,000 from 80,000 between 2003 and 2011. About 13 percent of all doctors are now employed directly by hospitals.”

A Necessary Change in Revenue Cycle Management Systems

Here is an article on the need for an overhaul of Revenue Cycle Management (RCM) systems in the U.S. It includes some stats on administration costs per transaction (compared to financial services transactions) and consolidation trends, as well as the value of analytics. Some excerpts…

“…the number of hospitals per integrated delivery system took a big jump last year from 6.4 to 7.1…”

“…the physicians who go into practice do not want to be entrepreneurs as much as they used to. When 52 or 53 percent of residents today become employees of integrated delivery systems, it tells you that the whole market has changed.”

Using Analytics to Maximize Revenues

Here is an article on using analytics and their reports to optimize financial operations.

So, what do you think?

P.S. Here is an interview that goes into the details of payer vs. provider, along with a case for more bundled payments. And here is a blog post that goes into more detail on bundled payments, including the shift from retrospective to prospective bundles.

P.P.S. Here is an article explaining the difference between charges and costs.

P.P.P.S. Here is a notice of rule changes proposed by CMS on the method by how physicians fees will be determined. “…we are updating our practice expense inputs for x-ray services to reflect that x-rays are currently done digitally rather than with analog film.”

P.P.P.P.S. Here is an article on a study on the disparity of costs for a Mammogram in the L.A. area. $60 to $254 for self-pay, with a bill of $694 to the insurance company for the same procedure elsewhere. 30% of Mammograms in the study were self-pay.

P.P.P.P.P.S Here is an article, with a nice infographic, on 5 common medical practice denials and remedies. Spoiler alert: Radiology made the Top 5 list of unexpected denials.

P.P.P.P.P.P.S Here is an infographic on the declining employment demand and income of Radiologists by a medical recruitment firm.

New JDI Article Published – Informatics Challenges—Lossy Compression in Medical Imaging

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An article I co-authored with Kinson Ho on the implications on informatics and information management when applying lossy compression to medical images in DICOM has been published. Check it out here.

It also explores whether wavelet-based compression (e.g. JPEG2000) still provides the value that it once promised. A comparison of different approaches to preserve system and network resources is included.

It is available in Journal of Digital Imaging.

The Gamification of Radiology

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Check out this article on gamification and clinicians.

In Radiology practices, obvious applications of gamification is using the inherent social pressure of it to improve report turnaround/signing times and peer review quota compliance. Or, even clinician satisfaction of the report.

It could also be used to provide reward/advantage to technologists that provide superior service to patients and acquire good quality imaging exams.

Participating in continuing education opportunities—say, like by attending the SIIM Annual Meeting—could also earn “points” toward rewards.

To work, it needs to be based on meaningful activities, include an aspect of social pressure and provide rewards that matter to the participants.

Article – Intelligent virtual assistants

dondennison Healthcare IT , , , ,

A friend sent me this article on “intelligent virtual assistants” today.

I think this type of technology has merit, but not in the applications that they describe. Accessing patient history information (“Accessing prior reports and specific report content”) or performing a query (“show me all unread chest CT cases”) is already solved with effective EPR client/data integration and proper worklist configuration.

Where this has merit, I believe, is when the new report is being created, and specific words are used, the assistant can then comb through the available data and automatically create links (e.g. a link to lesion measurements before and after cancer treatment), highlight key info to the physician (e.g. because they used the word “x”, some potentially important lab values automatically pop up in the corner as a notice), or in communication (e.g. initiating real-time consults with an available colleague from a list of appropriate specialists based on specific words being used in the report).

To have value, the assistant has to automate the mundane and has to deal with context across data formats, like scrolling through several pages of info in the EMR to see is any of it relates to the current exam (i.e. will impact the reader’s diagnosis).

Favorite Blog Posts of 2013

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As the first calendar year of my blog draw to a close, I thought I would compile a list of my favorite blog posts from 2013. I hope everyone has a safe, happy, healthy and prosperous New Year.

  1. 100th Blog Post: What I know about Software Development and Crisis Management
  2. The rise of the mobile-only user …and how this helps the underpriviliged
  3. Review of Stage 2 Meaningful Use Test Procedure for Image Results …and other MU tests
  4. Quebec EHR …the difference 2 years makes
  5. Video – Empathy: The Human Connection to Patient Care
  6. Designing for the ‘Public’ and the ‘Pros’
  7. Articles on Mobile Health Applications and FDA Regulation
  8. Plug-ins vs. APIs
  9. Article from HIMSS: PACS will not remain a self-contained data silo
  10. Blog posts on SIIM Web site (Part 1 and Part 2)

JDI Article Published – PACS 2018: An Autopsy

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An article I submitted to the Journal of Digital Imaging has been published electronically.

Told from the year 2018, it looks back at the market and technical forces that results in the deconstruction of PACS (and RIS) as we know it.

Check it out and let me know what you think.

Reflections on RSNA 2013

dondennison Radiology , , , , ,

I have attended the RSNA show for over a decade, but always as a vendor. My days consisted of many meetings with many customers of varying needs, trying to convince them that the products that our company made were superior to those offered across the aisle by the competitors.

This year was my first year as a consultant. I attended on behalf of clients, meeting with several vendors to discover how their solution could help my client meet their business and clinical objectives.

In short, I was on the other side of the fence for the first time. And it was enlightening.

First, as a vendor, you are on your feet for hours, actively listening, talking, and demonstrating software or presenting information at a high energy level. It is exhausting and your body feels it by the end of the show.

As an attendee, representing a recognized and respected healthcare institution, I had a much different experience. Upon arrival at the vendor’s booth, we (I was accompanied by one or more representatives from the hospital), were led to the comfy couches. We were offered water or coffee or a latte. Everyone was attentive and polite. I would be lying if I said that I did not enjoy this more than the grueling schedule of vendor staff (do thank them when you see them—they work very hard at RSNA).

My personal user experience aside, I had some observations on the way vendors manage the interaction with a potential (or existing) customer.

Caveat: I am not a sales person and have not been one in any capacity since working retail just out of high school. I do not profess to be a sales expert, but I have observed some of the best and worst at their craft, so I know some things about the art of selling.

Observation #1: Vendors do not ask enough questions

I thought this was Sales 101. Qualify the lead.

What problem are they trying to solve? Why did they come to the booth? What are they trying to learn/accomplish during the appointment? Where are they in the buying cycle? Do they have budget? Who is involved in making a decision? What solutions are under consideration?

It did vary from vendor to vendor, but I was amazed at how few questions were asked. Most just went right into their pitch, often trying to convince us of something that we already knew or believed.

Observation #2: Vendors fail to understand the roles of the people in the meeting

Vendors need to remember who the actual buyer is in the meeting. In every meeting, we clearly defined our titles and roles. I was always identified as a consultant. My client representatives were of roles that make buying decisions, yet in some meetings, the sales person made all their eye contact, and spoke directly, with me. In one case, they did this so much, I felt awkward for my client—they were practically ignored. Consultants may be decision influencers, but when you have an actual decision maker in the meeting, pitch to them.

Observation #3: Vendors don’t prepare well enough for meetings with existing customers

If you are a vendor that already does business with the customer, be prepared for the meeting. Know the outstanding issues that customer is having. Know which of your company’s products are installed there and what version they are on. Know the basic installation details (e.g. physical deployment) and which user communities are using the product.

If you don’t know these things, asking them in the meeting does not instill confidence in the customer, especially if there are some outstanding issues to be resolved.

And don’t tell the customer that they are the only one having these problems. It only makes them feel worse.

Observation #4: Solutions are stabilizing

I didn’t see anything that really amazed me. As a person involved mostly in product definition and development with a vendor, we were always told (often by sales people) that everyone else had amazing products and that we were so far behind. In my experience, the solutions offered in various categories do vary in their strengths, but none are abjectly poor at what they are intended to do.

The quality of sales professional varied more than the quality/functionality of the products offered, quite frankly.

In seeking solutions, it is not so much about finding the best product, but the product that fits the institution’s needs the best. Which requires that you know what those needs are, of course.

Observation #5: Analytics are evolving; So are monitoring solutions

Lots of vendors are offering some form of analytics package. Especially those offering products to optimize workflow (they get lots of info that they can make use of in those HL7 messages).

System monitoring is improving, but still have a ways to go. I think customers need to become better educated as to what is possible with a well-designed system monitoring solution, and the benefits (so that they can get the budget approval needed to put it in place).