Using Next-generation IT Tools to Improve Appropriateness

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imageRamin Khorasani, MD

It might well have been the unofficial theme of RSNA 2009 in Chicago, Illinois: “You can’t change what you can’t measure.” Opening his December 2 session on health IT with those very words, Ramin Khorasani, MD, outlined how next-generation IT tools can be leveraged by radiology departments and imaging centers to improve appropriateness and access. With American Recovery and Reinvestment Act (ARRA) stimulus funds earmarked specifically for health IT coming down the pike in 2010, the topic has never been more timely—and what use could be more meaningful than bringing down costs in imaging?

Khorasani, who is an associate professor in the department of radiology at Harvard Medical School and director of information management systems at Brigham & Women’s Hospital, Boston, Massachusetts, began by addressing a question that some in the audience might have been asking themselves: Why change? “What’s wrong with pencil and paper?” he asks. “Well, if you get a paper requisition, someone on the lower end of the payment scale enters the most important clinical information into your PACS. The tests ordered might not be appropriate, but there’s no way to stop the process until the patient actually arrives.”

That’s just one of a plethora of issues, Khorasani says. He notes that patient-safety information, such as renal dysfunction or allergies to contrast materials, might be missing from the requisition because the referring physician didn’t know that it should be included. Furthermore, most RIS platforms have a 256-character limit on text fields, so even if the referring physician did write a detailed requisition, information might be lost when the office receptionist enters the requisition into the RIS. Demographic and fiscal data might be incomplete or inaccurate. Requisitions could be illegible. There’s always the risk of transcription errors. The list, it seems, is endless.

Focusing on Waste

Khorasani observes that waste exists in every practice, estimating that even in his own practice, 10% to 20% of scans ordered might be inappropriate. “Everybody knows who the physicians are who order too much CT,” he says, adding, “It’s risk aversion.” To ameliorate the issue, his team has crafted an integrated system through which referring physicians order electronically, which subjects them to the use of clinical decision-support tools.

“If anyone in our system tries to order a radiology exam, we launch an application that allows him or her to order electronically; this is integrated into our electronic medical record and RIS/PACS environment and is connected to our payor database, so we get the acquisition number,” Khorasani explains. If a physician is unhappy with the decision-support module’s verdict on, say, a lumbar MRI, he or she can email Khorasani to protest. “How many emails do I get? Zero: This means we have beaten them into submission,” he laughs.

Khorasani’s practice also uses a homegrown analytics tool featuring real-time data analysis and display; the tool mines information from RIS, PACS, and reporting databases and is updated each day. Through the information compiled by the analytics tool, Khorasani can see that 60% of orders were entered into the system by physicians, for example, and can see what percentages of those referrers were primary care physicians or surgeons. He can also see how many ordering physicians are complying with evidence-based guidelines—currently 92%, up from 42% before the clinical decision-support tool was implemented. “This is the definition of meaningful use,” he says.

Productivity Boost

At the end of the day, Khorasani says, the system not only improves appropriateness and reduces waste; it also enhances physician productivity, both for referrers and radiologists. “Our referring physicians now bypass a very onerous paper-and-pencil utilization-management program from our payors,” he says. “For our radiologists, we’re getting access to clinical information we need at the point of care.”

Khorasani also touches on the importance of enabling users to gain imaging-network access across all of a medical center’s physical locations, irrespective of which RIS is being used at the point of care. “It’s very hard for an academic center to compete with OICs,” he notes. “By improving access across our organization, we’ve reduced leakage to OICs from 50% to 10%. In the process, we’ve swapped our referral patterns—and that’s quite all right.”

In summary, Khorasani says,