Health Imaging: Tools for Radiologists to Improve Interpretations, Quality, Outcomes
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Health Imaging: Tools for Radiologists to Improve Interpretations, Quality, Outcomes Lincoln L. Berland, M.D., F.A.C.R. Professor Emeritus, University of Alabama at Birmingham Chair, American College of Radiology Body Imaging Commission Karen Holzberger Vice President & General Manager Diagnostics, Healthcare Nuance Communications, Inc. Becker’s Hospital Review Annual Meeting April 28, 2016
Disclosure
– Consultant to Nuance Communications, Inc.
– Contributors/Acknowledgements
– Tarik Alkasab, MD, PhD
– Keith Dreyer, DO, PhD
© 2015 Nuance Communications, Inc. All rights reserved.
Key market dynamics driving Radiology
challenges
– Payment reform
– The journey from fee-for-service to value-based-reimbursements continues to
evolve
– Health system consolidation
– How are you rationalizing services and capturing volume?
– Deconstruction of PACS
– Best of breed strategies are becoming the foundation to solving larger
challenges
– Collecting key information “electronically”
– Radiology continues to be starved for information at key decision points
© 2015 Nuance Communications, Inc. All rights reserved.
Outcomes over output requires a new model
for data exchange Imaging 3.0
An Intuitive network that
Imaging 2.0 anticipates needs,
Imaging 1.0 Networks that supplies intelligence and
De-centralized CD send everything accelerates workflow
upload to eliminate
bottleneck in image
intensivists workflow
To meet
Has
today’s
Evolved
challenge
into
you need
© 2015 Nuance Communications, Inc. All rights reserved.
Connecting all Stakeholders
The world’s largest image and imaging data network
Connecting
physicians,
patients,
government
agencies, specialty
medical societies
and others as
simply as people
exchange
information using
social networks
© 2015 Nuance Communications, Inc. All rights reserved.
Creating a new model
– Expanding volume of information
– Legislative and regulatory mandates
– Radiology adapting to change
– Transforming the way we generate, manage medical information
– Deep learning on the horizon
© 2015 Nuance Communications, Inc. All rights reserved.
Expanding Applications and Information Demands
CMS Approves Lung Cancer Screening
on February 5th, 2015
© 2015 Nuance Communications, Inc. All rights reserved.
New Applications, PowerShare
Facilitated by Nuance PowerShare cloud-based information transfer
– Lung cancer screening
– Now approved by CMS up to 77, limited eligibility
– PowerShare (Nuance application that shares images and information among
institutions) will be able to help automate a highly manual process of data entry
into required, approved registries
– Colon cancer screening
– Being revisited this year by CMS
– Could lead to similar situation to LCS
© 2015 Nuance Communications, Inc. All rights reserved.
Frequency of Incidental Findings,
Recommendations
Furtado, C. D. et al. Whole-Body CT Screening: Spectrum of Findings
and Recommendations in 1192 Patients. Radiology 2005;237:385-394
Copyright ©Radiological Society of North America, 2005
© 2015 Nuance Communications, Inc. All rights reserved.Increased Recommendations
– 5.9 M studies from 1995-2008
– Odds of recommendations decreased by 15% per decade of
radiologist experience
Sistrom C L et al. Recommendations for Additional
Imaging in Radiology Reports: Multifactorial Analysis
of 5.9 Million Examinations. Radiology
2009;253:453-461
©2009 by Radiological Society of North America
© 2015 Nuance Communications, Inc. All rights reserved.Legislative Mandates
MACRA
MEDICARE ACCESS AND CHIP REAUTHORIZATION ACT (4.16.2015)
MIPS APM
(MERIT INCENTIVE PAYMENT SYSTEM) 2015 (ALTERNATIVE PAYMENT MODEL)
QUALITY PURCHASING SYSTEMS Fee for INNOVATIVE DELIVERY SYSTEMS
VALUE BASED MODIFIER (VBM) PAYMENTS ACO, MEDICAL HOME, BUNDLED PAYMENT
(PQRS, eCQM, CDS) MU CEHRT Service INITIATIVES
2019
MIPS APM
COMPOSITE SCORE ±4% 25% PARTICIPATION REQUIREMENTS
CPI
QUALITY
15%
MEASURES
2020
APM PARTICIPATION
30%
±5% 25%
- EP QUALITY MEASURES
2021 - MUST USE CEHRT
±7% 50% - BEAR FINANCIAL RISK
MU
CEHRT
- MEDICAL HOME STATUS
25%
RESOURCE
2022
USE
PERCENTAGE OF PAYMENTS FROM
30%
±9% 50% MEDICARE ATTRIBUTED TO APM
2023 © 2015 Nuance Communications, Inc. All rights reserved.
PAYMENT ADJUSTMENT (±9%) ±9% 75% PAYMENT ADJUSTMENT (+5%)Regulatory Timelines
Imaging 3.0 Portfolio
PAMA MACRA
2019 MACRA MANDATE 2019
2018 PAMA MANDATE MACRA QUALITY RECORDING 2018
REGULATORY DELAY REGULATORY WRITING
2017 2017
2016 ACR ASSIST 2016
REGULATORY WRITING
MACRA STATUE
2015 2015
PAMA STATUE
2014 2014
ACR SELECT
2013 2013
IMAGING 3.0
© 2015 Nuance Communications, Inc. All rights reserved.
ACR COMMON & ACR CONNECT“Medicare Says It Won’t Cover Hospital Errors “ “Cigna won't pay for 'never events‘”
Consumer’s Challenge Healthcare
CIGNA HealthCare is taking
steps to stop reimbursing
“‘It’s never just one thing’ that leads to serious harm” hospitals for so-called "never
events" and avoidable hospital
conditions, which are errors in
patient care that can and should
be prevented.
“Medicare's no-pay events: Coping with the complications”
“Blue Cross in Wisconsin won't pay for doctors' mistakes”
“Medicare won't cover hospitals' preventable errors”Pressure on Radiology
Courtesy John Crowe, M.D.
Pressure on Radiology
– Volume increasing
– Limitations on hiring (8 payment cuts in last decade)
– Increased stress, complexity, job security concerns
– Increased direct employment of radiologists
– Less control
– Less psychological investment
– Difficult to differentiate vision for change from feasible change, let alone
worthwhile change
© 2015 Nuance Communications, Inc. All rights reserved.Maximizing Radiologist Productivity
The Panopticon - Richard B. Gunderman, MD, Benjamin R. Gray, MD
(Satire on State of Radiology)
– Foucault: Discipline and Punish: The Birth of the Prison, 1977
– Describes the Panopticon devised by Jeremy Bentham in late 18th century as a method of
control
– [The Panopticon]… “consisted of a ring-shaped… layout of cells. In the center of the ring sat a
supervisor in a tower who, though invisible to the inmates, could see each of them…designed to
make inmates feel that they were under constant surveillance, eliminating any hope that they
could carry out plots in secret.”
– “Thanks to Bentham and Foucault… we have at last reached a historical juncture at which
every… misspent minute can be purged from the system. … technology is finally providing a
much more powerful means of ensuring that all radiologists work as hard as they possibly can all
of the time.”
© 2015 Nuance Communications, Inc. All rights reserved.Radiology Responding to Change: Imaging 3.0
Imaging 3.0
– Imaging 3.0 is Radiology’s Roadmap for transition from volume-based imaging to
value-based imaging care
– Maximizing radiologists’ value
– Collaborating with other physicians
– Leverages IT
– Empowering patients
– Enhances radiologists’ relevance
– Changing the discussion in Washington
© 2015 Nuance Communications, Inc. All rights reserved.Developing Medical Knowledge
Information
Take action
StopDiffusion of Medical Knowledge
Adherence to Recommendations
– Consistent processes determine quality
– Studies looking at compliance with recommendations:
– Ovarian cysts at ultrasonography: 59%,
– Variation among radiologists: 40-75%
– Critical-result renal masses on CT:
– Abdominal specialists: 93%
– Non-abdominal specialists: 57%
– As physicians, we are all held to the same standard. We are not allowed to say:
“Well, I really don’t know much about that stuff.”
© 2015 Nuance Communications, Inc. All rights reserved.Adoption of Evidence-Based Treatments
Margaret O’Kane, NCQA, 2008
© 2015 Nuance Communications, Inc. All rights reserved.Technology to Manage Medical Knowledge
Managing Medical Knowledge – The capacity of the brain to absorb, retain and use medical information was overwhelmed decades ago – Medical organizations have developed hundreds of guidelines – Yet, we still practice medicine “by hand” – by what we can remember and analyze – When we need detailed medical information – how do we find it?
Clinical Decision Support for Radiologist – ACR Assist & Nuance Clinical Guidance
Content Sources Clinical Guidance
ACR incidental findings white papers
X-RADS (e.g. LI-RADS, PI-
RADS, TI-RADS, etc.)
ACR actionable findings white
paper
Others: e.g. organ injury
classification
© 2015 Nuance Communications, Inc. All rights reserved.Lung Cancer Screening Registry
Li-RADS
Liver
cancer
© 2015 Nuance Communications, Inc. All rights reserved.Improving Report Quality
– Abdominal CT 95%
incidental Real-time access to
pulmonary nodule guidelines improves
compliance from 45%
No CT when indicated 45% to 95%
Follow-up CT too late
Follow-up CT too early
CT when not indicated Courtesy Keith Dreyer, DO, PhD
Concordant Tarik Alkasab, MD
M T Lu, MD, Boston, MA; D A Rosman, MD; C C Wu, MD; T K Alkasab, MD, PhD; J O Shepard, MD; G W Boland, MD;
et al. Impact of a Point-of-Care Electronic Clinical Decision Support (CDS) Tool on Adherence to Departmental
Guidelines for Follow-up of Incidental Pulmonary Nodules on Abdominal CT. RSNA 2013
© 2015 Nuance Communications, Inc. All rights reserved.Population Health Management
Clinical Decision Support
ORDERING
MANAGEMENT
DIAGNOSTIC
þCOUGH
þDYSPNIA
CDS
DISEASE
MANAGEMENT
þCT
CHEST
WITH
CONTRAST
DIAGNOSTICS
EMPHYSEMA / COPD
CARE PATHWAY
REPORTING
MANAGEMENT
INTERPRETIVE
þ
CDS
NODULE
ANALYSIS
CDS
CHF /CPARE EDEMA
PATHWAY
ULMONARY
þ
1.5CM
PERIPHERIAL
NODULE
FINDINGSPATIENT
AND
þ
MALIGNANT
FEATURES
COUGH
CLINICAL
þ
RECOMMENDATION:
BIOPSY
RECOMMENDATIONS
DYSPNIA
SCENARIO
ACUTEC
/CARE PNEUMONIA
PATHWAY
HRONIC
PROCEDURE
MANAGEMENT
PROCEDURE
þ
1.5
CM
SUSPICIOUS
NODULE
þ
PERCUTANEOUSLY
ACCESSIBLE
CDS
ADENOCARCINOMA, LUNG
CARE PATHWAY
þCT
GUIDED
NEEDLE
BIOPSY
PROCEDURES
þ
ADENOCARCINOMA,
LUNG
POPULATION
HEALTH
MANAGEMENT
Machine (Deep) Learning
Remarkably close to reality
– Will soon have machine learning for critical functions:
– Creating relevant clinical synopsis for radiologist
– Fetching relevant data and inserting into new report
– Collecting, organizing sequential treatment response data
– Soon:
– Enhanced computer aided detection and analysis
– Eventually:
– Image interpretation
© 2015 Nuance Communications, Inc. All rights reserved.Key Takeaways
– Pay attention to regulatory landscape
– Leverage Imaging 3.0 as guide for change
– Create new data model for medical knowledge, info sharing
– new applications
– social networks
– connect all stakeholders
© 2015 Nuance Communications, Inc. All rights reserved.“If you don’t like change,
you’ll like irrelevance even less”
Eric Shinseki
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