The New Normal in Imaging Utilization

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Health information exchanges, decision support tools and education provide strategies to ensure appropriate use in imaging.

Among Medicare beneficiaries, use of CT grew at an annual rate of 14.3 percent from 2000 to 2005 and magnetic resonance imaging (MRI) use rose at a 14 percent annual growth rate over the same period (Health Aff 2012:81876-1884). That growth decelerated by an average of 2.6 percent per year for MRI between 2006 and 2009. By 2010, there was a 1.7 percent decrease in CT use.

One could look at the slowdown in imaging utilization over the last few years as the new normal, and while some policy decisions have led to cuts in imaging use and costs, other factors could re-establish an upward trend. The recession has been partially credited with the decline in diagnostic imaging expenses, and as the economy recovers, a side effect could be an increase in imaging orders. The U.S. population is aging and will require more services, as will the millions of people being added to insurance plans, thanks to the Patient Protection and Affordable Care Act.

But a look at utilization alone doesn’t paint the whole picture.

“The question isn’t necessarily overall volume, the question is quality and appropriateness at a more granular level,” says Chris Sistrom, MD, PhD, MPH, of the University of Florida Health Center in Gainesville. Imaging has the potential to provide great value for diagnosis, so if imaging orders increase, it isn’t necessarily a problem as long as those orders meet appropriateness guidelines.

There’s a spectrum of physician behaviors with imaging, says Sistrom. On one end are those who willfully disregard guidelines. Others may be pressured by patients or liability concerns to order imaging that may not be clinically beneficial. On the other end are physicians who practice appropriate use of imaging, assisted by decision support. The goal should be moving more physicians into the latter category, he says.

Technology and workflow tools spark change and lead to more appropriate imaging. These strategies are set to spread as imaging appropriateness takes center stage.

Image exchange

Repeated diagnostic imaging studies are unnecessary in many cases, yet often are conducted because one provider doesn’t have access to prior studies conducted by another provider. CDs can be burned to transport the images, but this takes time and isn’t always practical in critical care cases. Approximately 2.2 million patients are transferred between emergency departments annually, and more than 480,000 CT exams could be ordered unnecessarily due to inaccessible CDs of prior images.

Enter the health information exchange (HIE), which facilitates the transfer of patient data between organizations, and increasingly the data include medical images. HealthInfoNet, a nonprofit health organization in Maine, is working on the first statewide medical image archive in the U.S. to support the state’s HIE.

“It’s fundamental to really make a change in healthcare and one of the areas is the exchange of critical patient information outside of the traditional organizational structures,” says Todd Rogow, director of IT at HealthInfoNet. He says health information used to be seen as proprietary data, but providers are learning that the data belong to the patient and can best be used for patient care if shared easily.

“Providers are frustrated because they need access when they need access,” says Cindy Harradon, regional director of medical imaging at Central Maine Medical Center in Lewiston, Maine, adding that problems arise especially when a patient needs a procedure, but the provider must wait to receive outside images.

In addition to better serving patients, image exchanges can save on costs. Maine’s image exchange project is still in the early stages, but HealthInfoNet estimates that Maine’s providers could save $6 million each over seven years through reduced data storage and transportation costs.

“Healthcare systems around the country are feeling a lot of pressure to lower the cost of care, and this is one way to do it,” says Denis Tanguay, CIO for Central Maine Healthcare. An image exchange isn’t a quick fix, says Tanguay, and with Meaningful Use, IT teams are spread thin, but the technology helps move providers in the right direction.

Decision support

The first step in implementing a strategy for increased appropriate use of imaging should be the use of a computerized decision support (CDS) system, says Sistrom. The results from facilities that use such systems lend credence to his suggestion.

For example, a study from HealthPartners Institute for Education and Research in Minneapolis found that a program using standardized CDS slowed the growth in ambulatory orders of high-tech diagnostic imaging. These systems provided a utility score during the ordering process, with alternate suggestions provided for low-scoring procedures.

A random audit of 300 charts for CT or MRI showed the proportion of orders fitting appropriate use criteria rose from 79 percent to 89 percent after implementation of the CDS. Pat Courneya, MD, health plan medical director for HealthPartners, says that in less than one year, more than half of the health plan’s membership was going to a medical group using decision support in ordering high-tech imaging and they found that physicians preferred the CDS system to receiving prior authorization from a radiology benefits manager (RBM).

“There’s just that natural recoil from the idea of having to do a ‘Captain, may I?’ style of approach,” says Courneya. Some providers did a workflow time analysis and found that CDS systems took only a few seconds, while calls to RBMs took an average of approximately 10 minutes per call.

“Overall, for those groups using decision support, the performance in terms of use of the technology was moderated to the same degree we would have expected with a more aggressive RBM strategy,” says Courneya.

Physician education

Aside from technological advances, simple low-tech educational interventions also can improve rates of appropriate imaging use, as seen in an initiative at the University of California, San Francisco (UCSF) Medical Center. There, a two-phase intervention targeting attending physicians and staff focused on cost and utilization data for commonly ordered radiographic tests, as well as radiation exposure data.

Presentation of cost data cut the mean number of tests ordered per 100 patient-days by 19.8 percent, and the second intervention, focused on dose, generated a reduction of 9.5 percent in ordered tests. Estimated annual direct cost savings to the hospital from the  interventions topped $108,000 and $78,000, respectively.

Naama Neeman, MSc, administrative director of quality and safety programs at UCSF, says a number of factors must come together to ensure appropriate use of imaging. “It’s going to be a combination of low- and high-tech strategies. Yes, we need more decision support tools, but more importantly, we also need to change the culture of overutilization. We need to educate our medical trainees about the associated costs and potential harm of over-testing, and immerse them in a different culture where more is not always better.”

When HealthPartners’ decision support program was rolling out, Courneya says the focus wasn’t just on reducing imaging utilization. “As a health plan, we believe this will probably reduce overall use, but for us, it would be enough to know that these technologies were being used the right way,” he says.

“We need to make sure we’re using those technologies where they’re appropriate, where they make the most difference, and not using them inappropriately, because that has the potential for harm,” Courneya notes. “We don’t want to reduce the overall benefit from these technologies by using them in ways that harm.”