Imaging Appropriateness, Without Emotion: An RPC Index Case Study

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 - Ray Montecalvo, MD, Medical Director for Virtual Radiologic (vRad)

Ray Montecalvo, MD, medical director for Virtual Radiologic (vRad), describes the key benefit of radiology analytics simply: they take emotion out of the equation. “From my twenty-five years of experience in the industry, it’s the squeaky wheel that often gets the grease,” he says. “When a hospital’s physicians feel like they need something, the story gets repeated until it reaches the ears of hospital administration - even if there’s no business case to support the request. That’s how a lot of decisions were made in the past; in the future, decisions without analytics demonstrating credible cost, benefit and patient impact just won’t cut it.”

In today’s constrained health care environment in which radiology groups are being paid less for ever-increasing volumes of work, it’s imperative that practices have insight into their own data when entering into conversations with their hospital customers, Montecalvo says. “Groups are finally waking up and realizing that the status quo is no longer an option; radiology must innovate once again in response to the consolidation of healthcare and the shift away from fee-for-volume.” 

Case in point: while there is a lot of focus and debate on future clinical decision support (CDS) models and requirements for appropriate imaging, Montecalvo maintains that private radiology groups can use analytics today to provide immediate value to their referring physicians and hospital administrators.  “There’s no margin of error anymore,” he observes, “The time to start becoming an indispensable partner can’t happen soon enough.”

Improving Service

In one example of how radiology analytics can create a fact-driven platform for productive conversations between physicians and hospital administration, a hospital client of vRad’s came seeking help with a request from a group of their referring physicians to add an additional full-time CAQ [Certificate of Added Qualification]Interventional Radiologist.  Montecalvo explains, “This particular hospital system has a big Medicaid population and is reliant on the state for some of its funding, but it also has a very successful oncology center.”   As a result, he says, any request coming from the oncologists is taken very seriously by the administration.

“The oncologists were requesting more access to higher-end interventional radiology work,” Montecalvo says, “and of course the CEO wants to keep them happy.”  Radiology modalities were reviewed and compared against vRad’s RPC Indices, the first findings-based national benchmarking metrics leveraging vRad’s clinical data warehouse of over 25 million studies.  Montecalvo explains, “This was the first time the hospital was able to see ‘inside their data’ and across their facilities, including functional IR volumes, patient-to-procedure ratios, referring physician findings and other quality performance metrics that had been unavailable because the hospital had no way to convert billing data into actionable insight, let alone normalize and benchmark their performance against peer groups.”

The referring physicians’ sense that a CAQ IR was needed was just that—a feeling not substantiated by the analytics.  “When we dove into the numbers, we saw there wasn’t nearly enough volume and RVU value to support a CAQ Interventionalist, in spite of what the oncologists believed,” explained Dr. Montecalvo.”  Instead, the analytics showed what the hospital could and should support: an additional mammographer.  “During the analysis, we identified that women’s imaging at the hospital was only at 50% of the national average for their peer group,” Montecalvo continued.  “This was an unexpected outcome given their patient and market demographics; they had the female population base to support a much higher level of mammogram activity.”

Armed with that information, the client’s radiologists were able to seek out a very specific type of colleague: one who could support the growth area of women’s imaging, while providing additional IR support as required.  “Our client physicians had the analytics and insight to have an unemotional, fact-based discussion,” explained Montecalvo.  “We were able to find the person who could really help them, as opposed to the person they thought they needed.”  That type of value add, according to Montecalvo, is what separates radiology groups into clinical vendors vs.  long-term patient care partners.

Improving Quality – with a Retrospective Look

But analytics are valuable for much more than improving service, Montecalvo observes. When it comes to identifying outliers in terms of appropriate ordering on the part of referring physicians, the data-driven approach facilitates what might otherwise be a difficult negotiation.  “Another client site was seeing a lot of MRIs being ordered out of the ED, even though MRI is not generally an emergency study,” he recalls. “Whenever you try to approach a physician about his ordering patterns, there is the potential for an uncomfortable conversation - especially if it’s a non-physician approaching about a clinical issue.”

By examining the imaging data, the vRad team was able to narrow down the majority of the orders to two ED physicians.  They were also able to show the percentage of findings benchmarked against other physicians at the hospital – and benchmarked against the hospital’s relevant peer group.  “The analytics allowed the hospital to go back to the ED physicians as a group and say we’ve noticed this and the radiologists are pretty sure there’s not a good clinical reason for it,” Montecalvo explains. “Misapprehension about discussing physician ordering patterns was overcome - but only because we were able to take the emotion out of it using evidence-based analytics.” 

According to Dr. Montecalvo, the client’s referring physicians were also appreciative of vRad’s retrospective approach to CDS: “Instead of having to change ordering patterns and clinical care ‘in the moment’ for all referring physicians, the group was able to use radiology analytics to identify and address the outliers.”  Montecalvo explains, however, that interactions and roundtables with referring physicians reinforce that solutions like vRad’s analytics are complementary to, not competitive with CDS to define and ensure the delivery of appropriate imaging. 

Going forward, of course, the hospital will be able to use analytics to assess whether the corrective action has had the intended effect on ordering, and also how future performance tracks against their peer groups.   Montecalvo says that this is the real potential of analytic solutions like the RPC Indices: creating an ongoing data-driven dialogue.  “Analytics give radiology the opportunity to build bridges and get alignment with our physician and hospital partners – reinforced with evidence, not emotion,” Montecalvo concludes.

Cat Vasko is a contributing writing for Medical Imaging Review