Decision support sweeps Minn., saves $84M
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| Image source: Diversified Radiology |
After three years of data covering five medical groups and more than one million CT, MRI, PET and nuclear imaging scans, and with the collaboration of nonprofits, medical groups, state government and vendors, Minnesota's major payors have jumped on board to contract clinical decision support (CDS) with their network providers. Picking up on these successes, Washington, D.C. and Washington state are inching closer to implementing similarly far-reaching measures, reshaping the way radiology exams are ordered.
The CDS cure
"It started about six or seven years ago, as concern about spiking imaging costs was really growing," explains Elizabeth Quam, executive director of the Center for Diagnostic Imaging (CDI) Quality Institute in Minneapolis. A group of several dozen outpatient imaging centers across 10 states, CDI was the earliest provider to adopt what will soon be a decision support tool that spans all of Minnesota. CDI teamed up with the Bloomington, Minn., nonprofit Institute for Clinical Systems Improvement (ICSI) to develop the CDS program, which the medical group CDI then convinced payors to be a viable alternative to radiology benefits management firms (RBMs), on a trial basis.
Following comprehensive documentation of exam orders, appropriateness and costs, the payors reported remarkable savings, Quam says. As a result, "the health plans went back to ICSI [the principal developer, whereas CDI was the primary clinical user] and asked the Institute to find a way to make this CDS available across the state." ICSI continued its collaboration with CDI and the Minnesota Department of Human Services, then selected a vendor to develop the program for statewide implementation. All the while, Quam was traveling between Capitol Hill and Washington state, highlighting two types of CDS: "One of the major benefits of clinical decision support is that it doesn't cause crabby doc syndrome, because physicians no longer have to deal with RBMs and the lengthy appeals process. When meeting with lawmakers, it's this second form of CDS that really resonates."
In the earliest phases of ICSI's CDS program development, clinicians working with CDI and ICSI assembled a "hodgepodge," albeit a rigorously evaluated one, of appropriate use criteria, principally taking from the American College of Radiology, the American College of Cardiology and the American College of Physicians.
Practices can use the CDS tool via two methods: a web portal or telephone. The ordering clinician must fill out a variety of fields, as with CPOE, meant to assess the appropriateness of the exam that the physician has selected. The CDS ranks the physician's choice on a scale of one to nine, offering alternative suggestions and access for the physician to evidence-based information as to why another exam may be more valuable. The program does not reject any exams—it only makes recommendations, while documenting all steps.
Outcomes
"First of all, it's so much cheaper and efficient for providers," says Quam. "To use RBMs instead of CDS would require an additional salaried person at many facilities—that's healthcare dollars at work. On top of this, physicians get the answer right away, whereas with RBMs it can take up to three days." Quam explains that in states where CDI cannot (yet) use the CDS tool, the group has a policy of appealing all RBM rejections, carrying on with confidence that the ordering clinician and the review by a specialized radiologist will eventually convince someone in the RBM appeals process that the exam is best for patient care, albeit after critical time has passed.
The clinical benefits provided by payors and ICSI, after limited application, are staggering:
• A 10 percent improvement in the diagnostic utility of exams compared with scans ordered via an RBM.
• Zero percent increase in claims for CT, MRI, PET and nuclear imaging scans between 2007 and 2010. From 2003 to 2006 claims for these modalities had risen by an average of 8 percent.
• An estimated $84 million savings in Minnesota healthcare costs in the trial because of fewer claims.
ICSI also points out that fewer exams result in less exposure to ionizing radiation among patients. According to Quam, the largest changes in ordering patterns have come from single-modality outpatient imaging centers, "the ones you often see in strip malls. This is because many times the CDS would recommend no exams and in other cases more appropriate exams were indicated."
Moving forward
With BlueCross BlueShield of Minnesota, HealthPartners Health Plan, Medica, UCare and DHS all on-board for adoption, the CDS tool is going through beta testing in preparation for voluntary statewide adoption. ICSI is currently working with the program's vendor to allow practices portal access to the system through ICSI's website. The nonprofit also is developing a modified version of the CDS, which takes the patient through similar steps as the ordering physician, with the goal of helping patients better understand the care they are receiving.
Quam is confident that CDS will be adopted by other states, with Washington recently passing legislation directly referencing the ICSI-CDI project. And as the new system spreads, Quam thinks an accreditation body, such as is used for EMRs, will be necessary to ensure quality CDS. Still, Quam sees RBMs as a major challenge to implementation, with many payors likely to cling to these "profit-centers."
In addition to the ICSI-provided outcomes, Quam maintains that "CDS is better for the patient, the payor and the physician. CDS tools document the appropriateness of healthcare given. Why wouldn't we want this?"