Altarum Institute, an industry leader in health information technology innovation is partnering with local provider organizations to implement a multi-faceted approach to reduce inappropriate utilization of advanced diagnostic imaging for over 750,000 patients in Michigan. The program, funded by the Centers for Medicare & Medicaid Innovation (CMMI) is a part of the strategy for funding programs that drive transformation by ensuring better health care and improved health and reduced costs for beneficiaries, ultimately enhancing health care for all Americans.
Our program is advancing the use of clinical decision support (CDS) for high-tech imaging by ordering providers, who obtain the latest in evidence-based guidance from the American College of Radiology (ACR) and the American College of Cardiology (ACC) prior to requisitioning high tech imaging exams.To further this initiative, we are promoting the use of alternate care (non-imaging) pathways, local best practices, and providing real-time education materials for imaging appropriateness and risks to reduce patient-induced demand. The program holds providers accountable by auditing ordering physician behavior and providing direct feedback and educational interventions for a targeted subset of outlier physician practices based on individual performance variance.
Advancing Decision Support
Integrating CDS into the ordering physician practice is an effective way to improve quality of care and ensure that imaging tests ordered are medically necessary and appropriate, through the design of a responsive and robust tool. ImageSmart™ provides real-time education to ordering physicians by embedding evidence-based guidelines from the American College of Radiology, the American College of Cardiology, and local recommendations. By complementing the evidence with local recommendations and valuable information about radiation exposure, prior test results, and local cost, physicians have all the pertinent information accessible to make appropriate care decisions when considering the need to order advanced diagnostic imaging.
Promoting adoption of technology is a critical and challenging factor in fostering change in health care delivery. Through a series of structured workflow studies, focus groups, and structured user interviews we have been able to design intuitive applications that can streamline existing process flows and facilitate behavior change.In addition to having all necessary information available in an organized and efficient fashion to support decision-making, it is also important to provide access to CDS through multiple points of entry including integration within the electronic health record (EHR), Web-enabled portals, and mobile (Android and iOS).
Promoting Alternate Care
Alternate care refers to non-radiologic treatment options that may be used when advanced imaging studies are deemed questionable in value and are unlikely to change treatment decisions or clinical outcomes. Promoting alternate care not only helps to reduce inappropriate advanced imaging use, but can serve to diminish the downstream effect of additional testing, unnecessary surgeries, and care delays that are costly and bring little additional value to patients. Such pathways may involve lower cost diagnostic tests in place of an advanced imaging study, deferring a study to a more suitable timeframe, or coordinating referral practices in lieu of imaging.
Working with a cross-specialty clinical panel of physicians, we have developed more than 100 recommendations that are displayed for users to consider when the professional society criteria content provided is redundant or includes conflicting recommendations to the ordering provider. These recommendations provide guidance for image selection or by highlighting when non-radiologic options such as specialty consultation or other forms of treatment (i.e., conservative therapy for example) would be appropriate.
Reducing Patient Demand
The imaging program developed by Altarum demonstrates the importance of patient engagement and shared decision making concurrent with the clinical decision making process in an ongoing effort to achieve better health outcomes. Involving the patient and the medical provider during the test selection and ordering process supports the ability to improve the patient’s understanding of diagnosis, treatment options, adherence, and behavior modification to allow for a more narrowed focus on patient centered care and planning.
Patient education materials for eight clinical areas including: imaging for low-back, shoulder, knee, hip and neck pain, sinusitis, headache, and kidney stones have been developed by isolating high-volume exams that lend themselves to inappropriate ordering and variability in practice as verified by claims data. The CDS tool presents practitioners with educational materials through a real-time basis to provide patients with pertinent information regarding options for self-care, radiation exposure, and local cost implications. Access to patient educational materials is important to support the ordering practitioner’s ability to mitigate patient demand for imaging tests that may not be medically indicated. And, combining patient engagement through education and shared decision making will lead to a more sustainable model and create a more significant impact to overall imaging utilization than with CDS alone.
Leveraging Provider Accountability
Monitoring provider-level performance and adherence to guidelines is critical to meeting the objective of reducing unnecessary imaging. Frequent communication of dashboards and profiles designed to measure program adoption, and appropriateness, including peer comparisons, can be essential in creating a culture for change. Altarum has developed an easy access Dashboard containing a personalized visual depiction providing access to the provider’s ImageSmart™ CDS selections for self assessment, comparison of their usage to their peers, and monitoring outlier status.
Altarum and our clinical partners have extensive analytic experience to identify issues of system-wide performance as well as monitoring individual providers whose behavior falls outside an acceptable range of variation. Physician organization medical directors work directly with underperforming physicians to identify performance problems and remediation strategies to reduce unwarranted variation in practice and bring outlier practices into an acceptable utilization range. Supporting providers with real-time evidence, actionable data, and face-to-face interventions have been successful strategies in reducing inappropriate use of advanced diagnostic imaging.