Imaging Appropriateness Made Easy 

Quality experts weigh in on the radiologist’s important role in ensuring imaging appropriateness.

May 2015

During the ACR 2015 presentation titled “Imaging Appropriateness in the Era of Imaging 3.0,” Margaret Ferguson, MD, vice president and chief value officer at the Colorado Permanente Medical Group, pinpointed an issue facing much of radiology: radiologists are often blamed for inappropriate imaging when, in fact, it’s not their fault. To combat this perception problem, radiologists should not grow frustrated but, instead, take action.

“We need to enhance the radiologist’s value throughout the ordering spectrum,” noted Ferguson, “to reduce unwarranted variation in ordering practices and provide better clinical care for our patients.” The problem, she went on to say, is that in the past, radiologists have focused too much on interpreting images. Looking forward, she explained, the real value of radiologists, both clinically and financially, will be found in how they serve as consultants for the ordering of images and provide guidance on how ordering physicians should act upon their findings.

The reasons for pervasive inappropriate ordering of images are many, according to Bruce J. Hillman, MD, FACR, editor-in-chief of the JACR® and founder and chief scientific officer of ACR Image Metrix. Busy physicians misusing advanced imaging in an unfocused manner as a triage tool, referring clinicians’ desire to honor patient requests and retain loyalty, and mandates for greater productivity, noted Hillman, are some of the top reasons that imaging costs have, until recently, skyrocketed. However, the days of limitless ordering have ended as a result of mandates from Health and Human Services emphasizing CMS reimbursement based on quality metrics.

Given the changes afoot, how can radiologists best serve as proactive members of the clinical care team to help mitigate cost, not to mention ensure that patients receive appropriate imaging? One of the most promising ways, argued E. Kent Yucel, MD, FACR, radiologist-in-chief at Tufts University School of Medicine, is through increased reliance on ACR Appropriateness Criteria® and the criteria’s electronic version, ACR Select®. ACR Select places radiologists in the role of imaging consultant, a resource that referring clinicians can draw upon when they have questions about the software’s recommendations. Clinical decision support technology like ACR Select was given a boost with the recent ruling that, by January 1, 2017, Medicare will no longer reimburse rendering providers for advanced imaging services unless the ordering physician has consulted with appropriate use criteria before making the order.

As the landscape shifts away from incentives to over-order and toward motivations to order appropriately, radiologists must continue to demonstrate their value. One opportunity for doing so comes with the periodic requirement to engage in PQI projects for part 4 of radiologists’ maintenance of certification. Ruth C. Carlos, MD, MS, FACR, professor and assistant chair of clinical research in the department of radiology at the University of Michigan and deputy editor of the JACR, asserted that it is of paramount importance to choose the right PQI project to exhibit radiology’s vital role in quality assurance.

PQI project teams should include an ordering physician, a radiologist, a technologist, a departmental manager, and a support person. Crucially important, emphasized Carlos, the team must have departmental leadership support. To garner this support, radiologists must be up-front about “who’s going to win, who’s going to lose, who will have to do more work, and who will have to do less work if your project succeeds.”

As an example of one such successful PQI project, Jennifer C. Broder, MD, assistant professor of radiology at Tufts Medical School and radiologist at Lahey Hospital and Medical Center, discussed her engagement with ACR’s Value-Based Radiology PQI Project. This project was designed by the ACR to help radiologists with a simple step-by-step process for completing a quality improvement project and learning to engage with ordering physicians. Broder stated that the ACR’s PQI project provides a fast registration format, efficient data collection, and results that are automatically calculated for participants. Other advantages of the project include a pre-selected list of topics based on the Choosing Wisely® campaign, along with resources available to help walk radiologists through how to approach referring clinicians about performing educational interventions in referrers’ workflow.

Quality patient-centered care is gaining recognition as an important component of physicians’ work. Radiologists must take a more active role in patient care, on par with primary care physicians. Ways to do so include lobbying your institution to adopt clinical decision support technology like ACR Select, as well as engaging in meaningful PQI projects.

By Chris Hobson, Imaging 3.0 content manager

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