Showing papers by "Richard Duszak published in 2015"

A Comparison of Diagnostic Imaging Ordering Patterns Between Advanced Practice Clinicians and Primary Care Physicians Following Office-Based Evaluation and Management Visits

Abstract: Importance Little is known about the use of diagnostic testing, such as medical imaging, by advanced practice clinicians (APCs), specifically, nurse practitioners and physician assistants. Objective To examine the use of diagnostic imaging ordered by APCs relative to that of primary care physicians (PCPs) following office-based encounters. Design, Setting, and Participants Using 2010-2011 Medicare claims for a 5% sample of beneficiaries, we compared diagnostic imaging ordering between APC and PCP episodes of care, controlling for geographic variation, patient demographics, and Charlson Comorbidity Index scores. Provider specialty codes were used to identify PCPs and APCs (general practice, family practice, or internal medicine for PCP; nurse practitioner or physician assistant for APC). Episodes were constructed using evaluation and management (EM (2) no claims within the subsequent 30 days other than a single imaging event; or (3) claims for any nonimaging services in that subsequent 30-day period. Main Outcomes and Measures The primary outcome was whether an imaging event followed a qualifying E&M visit. Results Advanced practice clinicians and PCPs ordered imaging in 2.8% and 1.9% episodes of care, respectively. In adjusted estimates and across all patient groups and imaging services, APCs were associated with more imaging than PCPs (odds ratio [OR], 1.34 [95% CI, 1.27-1.42]), ordering 0.3% more images per episode. Advanced practice clinicians were associated with increased radiography orders on both new (OR, 1.36 [95% CI, 1.13-1.66]) and established (OR, 1.33 [95% CI, 1.24-1.43]) patients, ordering 0.3% and 0.2% more images per episode of care, respectively. For advanced imaging, APCs were associated with increased imaging on established patients (OR, 1.28 [95% CI, 1.14-1.44]), ordering 0.1% more images, but were not significantly different from PCPs ordering imaging on new patients. Conclusions and Relevance Advanced practice clinicians are associated with more imaging services than PCPs for similar patients during E&M office visits. Expanding the use of APCs may alleviate PCP shortages. While increased use of imaging appears modest for individual patients, this increase may have ramifications on care and overall costs at the population level.

Trends in lumbar puncture over 2 decades: a dramatic shift to radiology.

Abstract: OBJECTIVE. The purpose of this study is to evaluate national trends in lumbar puncture (LP) procedures and the relative roles of specialty groups providing this service. MATERIALS AND METHODS. Aggregated claims data for LPs were extracted from Medicare Physician Supplier Procedure Summary master files annually from 1991 through 2011. LP procedure volumes by specialty group and place of service were studied. RESULTS. Between 1991 and 2011, the overall numbers of LP procedures increased, with a slight increase in diagnostic LP procedures (90,460 vs 90,785) and a marked increase in therapeutic LP procedures (2868 vs 6461) in Medicare fee-for-service beneficiaries. Although radiologists performed 11.3% (n = 10,533) of all LP procedures in 1991, they performed 46.6% (n = 45,338) in 2011. For diagnostic LPs, radiology (11.4% [n = 10,272] in 1991 and 48.0% [n = 43,601] in 2011) now exceeds emergency medicine, neurosciences, and all others as the dominant provider group. For therapeutic LP procedures, radiology n...

Diagnostic Radiology Resident and Fellow Workloads: A 12-Year Longitudinal Trend Analysis Using National Medicare Aggregate Claims Data

Abstract: Purpose The aim of this study was to evaluate changes in diagnostic radiology resident and fellow workloads in recent years. Methods Berenson-Eggers Type of Service categorization was applied to Medicare Part B Physician/Supplier Procedure Summary Master Files to identify total and resident-specific claims for radiologist imaging services between 1998 and 2010. Data were extracted and subgroup analytics performed by modality. Volumes were annually normalized for active diagnostic radiology trainees. Results From 1998 to 2010, Medicare claims for imaging services rendered by radiologists increased from 78,901,255 to 105,252,599 (+33.4%). Service volumes increased across all modalities: for radiography from 55,661,683 to 59,654,659 (+7.2%), for mammography from 5,780,624 to 6,570,673 (+13.7%), for ultrasound from 5,851,864 to 9,853,459 (+68.4%), for CT from 9,351,780 to 22,527,488 (+140.9%), and for MR from 2,255,304 to 6,646,320 (+194.7%). Total trainee services nationally increased 3 times as rapidly. On an average per trainee basis, however, the average number of diagnostic services rendered annually to Medicare Part B beneficiaries increased from 499 to 629 (+26.1%). By modality, this represents an average change from 333 to 306 examinations (−8.1%) for radiography, from 20 to 18 (−7.4%) for mammography, from 37 to 56 (+49.7%) for ultrasound, from 88 to 202 (+129.1%) for CT, and from 20 to 47 (+132.0%) for MRI. Conclusions Between 1998 and 2010, the number of imaging examinations interpreted by diagnostic radiology residents and fellows on Medicare beneficiaries increased on average by 26% per trainee, with growth largely accounted for by disproportionate increases in more complex services (CT and MRI).

Expanding Roles of Nurse Practitioners and Physician Assistants As Providers of Nonvascular Invasive Radiology Procedures

Abstract: Purpose: To evaluate national trends in nonvascular invasive radiology procedures performed by advanced practice providers (APPs), focusing specifically on nurse practitioners and physician assistants. Methods: Nonvascular invasive radiology procedures commonly performed by APPs at our 2 largest hospitals were used to identify procedure groups for national trends analysis. We mapped categories of services annually to then-current Current Procedural Terminology codes from 1994 to 2012 and identified national Medicare Part B beneficiary paid claims frequency using Physician Supplier Procedure Summary Master Files. Trends were studied for APPs, radiologists, and all providers nationally for 7 categories of service: paracentesis, thoracentesis, fine-needle aspiration (FNA), superficial lymph node biopsy, abdominal biopsy, thoracic biopsy, and abdominal drainage. Results: Of 1,352 nonvascular invasive procedures performed by APPs at our facilities over a 1-year period through August 2013, a total of 1,161 (85.9%) fell into the 7 defined categories. Between 1994 and 2012, national Medicare claims by APPs increased dramatically for all of these categories: paracentesis from 0 to 17,967; thoracentesis from 119 to 4,141 (þ3,379%); FNA from 0 to 3,921; superficial lymph nodebiopsyfrom0to251;abdominalbiopsyfrom1to1,819(þ1,818%);thoracicbiopsyfrom0to552;andabdominaldrainagefrom37to 410 (þ1,008%). Overall, volumes increased for both radiologists and all providers, with the total fraction of national services performed by APPs increasing from 0% to 10.7% for paracentesis, 0.1% to 5.7% for thoracentesis, 0% to 2.1% for FNA, 0% to 1.4% for superficial lymph node biopsy, 0% to 1.7% for abdominal biopsy, 0% to 1.0% for thoracic biopsy, and 0.1% to 1.2% for abdominal drainage. Conclusions: Although APPs perform a relatively small portion of commonly performed nonvascular invasive radiology procedures nationally, paid Medicare claims for those services have increased dramatically over nearly 2 decades, and at a faster pace than that for all providers as a whole. Given the multiple hurdles involved in obtaining Medicare reimbursement, that growth indicates increasing acceptance of APPs as procedure service providers at the institutional credentialing, state licensure, and payer policy levels.

Traditional text-only versus multimedia-enhanced radiology reporting: referring physicians' perceptions of value.

Abstract: Purpose The aim of this study was to evaluate referring physicians' perceptions of multimedia-enhanced radiology reporting (MERR) as an alternative to traditional text-only radiology reporting. MERR supplements text-only reports by embedding user-friendly interactive hyperlinks to key images and graphically plotting target lesion size longitudinally over time. Methods Of 402 physicians responding to a web-based survey, 200 (50 each medical oncologists, radiation oncologists, neurosurgeons, and pulmonologists) practicing in the United States fulfilled criteria to complete an online survey with questions focusing on satisfaction with current text-only reports and the perceived value of image- and data-enriched reporting. Results The mean respondent age was 46 years, with a mean of 15 years in posttraining clinical practice (85% men; 47% from academic medical centers). Although 80% were satisfied with the format of their current text-only radiology reports, 80% believed that MERR would represent an improvement. The most commonly reported advantages of MERR were "improved understanding of radiology findings by correlating images to text reports" (86%) and "easier access to images while monitoring progression of a disease/condition" (79%). Of the 28% of physicians with concerns about MERR implementation, the most common were that it was "too time intensive" (53%) and "the clinic workflow does not allow itself to view reports in such a fashion" (42%). Physicians indicated a strong increased likelihood of preferentially referring patients to (80%) and recommending peers to (79%) facilities that offer MERR. Conclusion Most specialist referring physicians believe that interactive image- and data-embedded MERR represents an improvement over current text-only radiology reporting. Compared with current report formatting, most would preferentially refer patients and peers to facilities offering more meaningful image- and graphically enriched reporting platforms.

Physician Rating Websites: Do Radiologists Have an Online Presence?

Abstract: Purpose Given that patient satisfaction and provider transparency intersect on online physician-rating websites, we aimed to assess radiologist representation on these increasingly popular sites. Methods From a directory of all Medicare participating physicians, we randomly selected 1,000 self-designated diagnostic radiologists and manually extracted their rating information from five popular online physician-review websites (HealthGrades, Healthcare Reviews, RateMDs, Kudzu, and Yelp). Using automated web "data-scraping" techniques, we separately extracted all radiologist and nonradiologist rating information from a single amenable site (Healthcare Reviews). Rating characteristics were analyzed. Results Of 1,000 sampled self-designated diagnostic radiologists representing all 50 states, only 197 (19.7%) were profiled on any of the five online physician-review websites. Only 24 (2.4%) were rated on two of the sites, and none was profiled on ≥3 sites. Of all 6,775 physicians listed on a single electronically interrogated site, only 30 (0.4%) were radiologists. With 28,555 (5.2%) of all 547,849 Medicare-participating physicians identified as diagnostic radiologists, radiologists were thus significantly underrepresented online ( P P = .22), radiologists were rated (on a low to high score of 1 to 10) significantly higher than nonradiologists (median 8.5 versus 5, P = .04). Conclusions Most diagnostic radiologists are not profiled on common online physician-rating websites, and they are significantly underrepresented compared with nonradiologists. Reviewed radiologists, however, scored favorably. Given the potential for patient satisfaction scores and public domain information to affect referrals and future value-based payments, initiatives to enhance radiologists' online presence are advised.

Screening Mammography Rates in the Medicare Population before and after the 2009 U.S. Preventive Services Task Force Guideline Change: An Interrupted Time Series Analysis.

Abstract: Objective: We sought to examine longitudinal trends in screening mammography utilization and the presence of any changes in utilization associated with the 2009 U.S. Preventive Services Task Force (USPSTF) guideline change. Methods: We use 2005 through 2012 Medicare fee-for-service claims data for a 5% sample of randomly selected beneficiaries. The primary outcome is monthly mammography rate per 1,000 women. Two comparison outcomes are monthly Papanicolaou test rate and monthly routine eye examination rate. The statistical approach is interrupted time series with segmented regression analysis and nonequivalent dependent variables. Results: Among women age 65 and 90, monthly screening mammography rates were significantly increasing before the 2009 USPSTF guideline change. Immediately after the guidelines, there was a significant drop of 1.76 per 1,000 women (p < .001). Three years after the guideline, and after the initial decrease, there was no significant change in rate for those aged 65 to 74, but a continued and significant decline for those aged 75 and older. Two other preventive services (Papanicolaou test and routine eye examinations) did not show any shift associated with the pre- and post-guideline window. Conclusions: The 2009 revision of USPSTF guidelines on breast cancer was associated with an immediate and significant decrease in screening mammography rates. The long-term impact of the guideline change differs by age and race and may not be fully quantifiable for years after its implementation. Copyright 2015 by the Jacobs Institute of Women’s Health. Published by Elsevier Inc.

How Much Do Common Imaging Studies Cost? A Nationwide Survey of Radiology Trainees.

Abstract: OBJECTIVE. The objective of this study was to gauge the knowledge of radiology trainees regarding the costs of common imaging services and to assess their perceptions of current relevant education. SUBJECTS AND METHODS. During mid-2014, an online survey of 5325 U.S. residents and fellows who were members of the American College of Radiology was conducted. Respondents were asked to provide information about year of training, relevant advanced degrees (e.g., Master of Business Administration or Master of Public Health), number of hours of formal education in health care economics provided annually by their training program, self-perception of knowledge of health care economics, and desire to learn more about the costs of imaging. Respondents were asked to estimate Medicare-allowable fees for five commonly performed imaging examinations: two-view chest radiography, contrast-enhanced CT of the abdomen and pelvis, unenhanced MRI of the lumbar spine, complete abdominal ultrasound, and unenhanced CT of the brain...

The Impact of Hospital Characteristics on the Availability of Radiology Services at Critical Access Hospitals

Abstract: Purpose Although all critical access hospitals (CAHs) provide basic medical and radiographic imaging services, it remains unclear how CAHs provide additional imaging services given relatively low patient volumes and high resource costs. The aim of this study was to examine whether CAHs with more resources or access to resources through affiliation with larger systems are more likely to offer other imaging services in their communities. Methods Linking data from the American Hospital Association's annual hospital surveys and the American Hospital Directory's annual surveys from 2009 to 2011, multivariate logistic regressions were performed to estimate the likelihood of individual CAHs with greater financial resources or network affiliations providing specific imaging services (MRI, CT, ultrasound, mammography, and PET/CT), while adjusting for the number of beds, personnel, inpatient revenue share, case mix, rural status, year, and geographic location. Results Hospital total expenditures were positively associated with the provision of MRI (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.07-1.19), mammography (OR, 1.11; 95% CI, 1.01-1.16), and PET/CT (OR, 1.04; 95% CI, 1.01-1.06). Network affiliation was positively associated with the availability of MRI (OR, 1.75; 95% CI, 1.27-2.39), CT (OR, 2.17; 95% CI, 1.15-4.09), ultrasound (OR, 2.03; 95% CI, 1.17-3.52), and mammography (OR, 2.00; 95% CI, 1.47-2.71). Rural location was negatively associated with the availability of PET/CT (OR, 0.65; 95% CI, 0.49-0.88). Conclusions Total hospital expenditures and network participation are important determinants of whether CAHs provide certain imaging services. Encouraging CAHs' participation in larger systems or networks may facilitate access to highly specialized services in rural and underserved areas.

The impact of nonphysician providers on diagnostic and interventional radiology practices: regulatory, billing, and compliance perspectives.

Abstract: The numbers of nurse practitioners and physician assistants are increasing throughout the entire health care enterprise, and a similar expansion continues within radiology. Some practices have instead embraced radiologist assistants. The increased volume of services rendered by this growing nonphysician provider subset of the health care workforce within and outside of radiology departments warrants closer review. The authors evaluate the recent literature and offer recommendations to radiology practices regarding both regulatory and scope-of-practice issues related to these professionals. Additionally, billing and compliance issues for care provided by nurse practitioners, physician assistants, and radiologist assistants are detailed. An analysis of the integration of these professionals into interventional and diagnostic radiology practices, as well as potential implications for medical education, is provided in the second part of this series.

The Health Care Value Transparency Movement and Its Implications for Radiology

Abstract: The US health care system is in the midst of disruptive changes intended to expand access, improve outcomes, and lower costs. As part of this movement, a growing number of stakeholders have advocated dramatically increasing consumer transparency into the quality and price of health care services. The authors review the general movement toward American health care value transparency within the public, private, and nonprofit sectors, with an emphasis on those initiatives most relevant to radiology. They conclude that radiology, along with other "ancillary services," has been a major focus of early efforts to enhance consumer price transparency. By contrast, radiology as a field remains in the "middle of the pack" with regard to quality transparency. There is thus the danger that radiology value transparency in its current form will stimulate primarily price-based competition, erode provider profit margins, and disincentivize quality. The authors conclude with suggested actions radiologists can take to ensure that a more optimal balance is struck between quality transparency and price transparency, one that will enable true value-based competition among radiologists rather than commoditization.

Regional variation in Medicare payments for medical imaging: radiologists versus nonradiologists.

Abstract: OBJECTIVE. The purpose of this article was to study regional variation in Medicare Physician Fee Schedule (MPFS) payments for medical imaging to radiologists compared with nonradiologists. MATERIALS AND METHODS. Using a 5% random sample of all Medicare enrollees, which covered approximately 2.5 million Part B beneficiaries in 2011, total professional-only, technical-only, and global MPFS spending was calculated on a state-by-state and United States Census Bureau regional basis for all Medicare Berenson-Eggers Type of Service–defined medical imaging services. Payments to radiologists versus nonradiologists were identified and variation was analyzed. RESULTS. Nationally, mean MPFS medical imaging spending per Medicare beneficiary was $207.17 ($95.71 [46.2%] to radiologists vs $111.46 [53.8%] to nonradiologists). Of professional-only (typically interpretation) payments, 20.6% went to nonradiologists. Of technical-only (typically owned equipment) payments, 84.9% went to nonradiologists. Of global (both profes...

The Impact of Nonphysician Providers on Diagnostic and Interventional Radiology Practices: Operational and Educational Implications.

Abstract: The numbers of nurse practitioners (NPs) and physician assistants (PAs) are increasing throughout the entire health care enterprise, and a similar expansion continues within radiology. The use of radiologist assistants is growing in some radiology practices as well. The increased volume of services rendered by this growing nonphysician provider subset of the health care workforce within and outside radiology departments warrants closer review, particularly with regard to their potential influence on radiology education and medical imaging resource utilization. In this article (the second in a two-part series), the authors review recent literature and offer recommendations for radiology practices regarding the impact NPs, PAs, and radiologist assistants may have on interventional and diagnostic radiology practices. Their potential impact on medical education is also discussed. Finally, staffing for radiology departments, as a result of an enlarging nonradiology NP and PA workforce ordering diagnostic imaging, is considered.

Magnitude of Impact, Overall and on Subspecialties, of Transitioning in Radiology from ICD-9 to ICD-10 Codes

Abstract: Purpose Converting the nation’s International Classification of Diseases (ICD) diagnosis coding system, from 14,025 ICD-9 to 69,823 ICD-10 codes, is projected to have enormous financial and operational implications. We aimed to assess the magnitude of impact that this code conversion will have on radiology claims. Methods The most frequently billed ICD-9 diagnosis codes for 588,523 radiology claims from five hospitals and affiliated outpatient sites during a 12-month period were mapped to matching ICD-10 codes using a Medicare-endorsed tool. The code-conversion impact factor was calculated for the entire radiology system, and each individual subspecialty division. Results Of all ICD-9 codes, only 3,407 (24.3%) were used to report any primary diagnosis. Of all claims, 50% were billed using just 37 (0.3%) primary codes; 75% with 131 (0.5%), and 90% with 348 (2.5%). Those 348 ICD-9 codes mapped onto 2,048 ICD-10 codes (5.9-fold impact), representing just 2.9% of all ICD-10 codes. By subspecialty, the conversion impact factor varied greatly, from 1.1 for breast (11 ICD-9 to 12 ICD-10 codes) to 28.8 for musculoskeletal imaging (146 to 4,199). The community division, reflecting a general practice mix, saw a conversion impact factor of 5.8 (254 to 1,471). Conclusions Fewer than 3% of all ICD-9 and ICD-10 codes are used to report an overwhelming majority of all radiology claims. Although the number of commonly used codes will expand 5.9-fold overall, musculoskeletal imaging will experience a projected 28.8-fold explosion. Radiology practices should target their ICD educational and operational conversion efforts in an evidence-based manner.

Structured Reporting and Communication

Abstract: In a previous article in this series, we stressed that the ultimate product of the imaging value chain is the timely delivery of actionable information to the requesting referrer— and now increasingly to the patient [1]. For this to occur, radiologists must optimize each value activity within the value chain (examination request, protocoling, image production, and presentation for interpretation). Suboptimal performance in any one of these domains limits the ability to compose an actionable report. Actionable reporting is one of the key tenets of Imaging 3.0 , whereby radiologists present both referrers and patients with information they can act upon. That information must minimize ambiguity and equivocation and be succinct, appropriately directional (ie, minimizing unnecessary additional tasks, tests, and time), and precise. In other words, reports should answer specific contextual questions that then facilitate care in the most expeditious, least harmful, and most cost-effective manner. In this penultimate article in the “Imaging Value Chain” series, we focus on what strategies and tools radiologists can exploit to optimize their reporting performance (through interpretation, composition, and communication) to meet the objective of actionable reporting. For the sake of this discussion, it can be assumed that imaging appropriateness, protocol

State Variation in Medical Imaging: Despite Great Variation, the Medicare Spending Decline Continues

Abstract: OBJECTIVE. The purpose of this study was to assess state-level trends in per beneficiary Medicare spending on medical imaging. MATERIALS AND METHODS. Medicare part B 5% research identifiable files from 2004 through 2012 were used to compute national and state-by-state annual average per beneficiary spending on imaging. State-to-state geographic variation and temporal trends were analyzed. RESULTS. National average per beneficiary Medicare part B spending on imaging increased 7.8% annually between 2004 ($350.54) and its peak in 2006 ($405.41) then decreased 4.4% annually between 2006 and 2012 ($298.63). In 2012, annual per beneficiary spending was highest in Florida ($367.25) and New York ($355.67) and lowest in Ohio ($67.08) and Vermont ($72.78). Maximum state-to-state geographic variation increased over time, with the ratio of highest-spending state to lowest-spending state increasing from 4.0 in 2004 to 5.5 in 2012. Spending in nearly all states decreased since peaks in 2005 (six states) or 2006 (43 sta...

Practice Management and Health Policy Education in Radiology: An Emerging Imperative.

Abstract: As society places increased responsibility on practicing physicians for addressing accelerating health care costs and delivery system inefficiencies, traditional education and training programs have left most physicians ill equipped to assume this responsibility. A variety of new initiatives are underway that dramatically change how radiology training programs address these issues. We review the emerging need for better physician education in health policy and practice management, detail the history and requirements of the ACGME and the ABR Healthcare Economics Milestone Project, and outline mechanisms by which radiology residency programs can comply with these requirements. We describe our own new comprehensive pilot curriculum, Practice Management, Health Policy, and Professionalism for Radiology Residents (P(3)R(2)), which may serve as a potential model for other training programs seeking to develop targeted curricula in these newly required areas.

Business Intelligence, Data Mining, and Future Trends

Abstract: This series has endeavored to direct the thinking and mind-set of radiologists to embrace the ACR’s Imaging 3.0 strategic initiative through the concept of the imaging value chain. This vision was in response to the complex and uncertain changes afoot in health care policy, delivery, and reimbursement. A fundamental tenet of health care reform is the move from a transactional fee-for-service model to one that is value driven and focused on patient outcomes—the “volumeto-value” paradigm. In response, the health care profession has yet to fully understand, grasp, and reengineer its workflow, but Imaging 3.0 serves as a roadmap for radiologists to gear their businesses toward delivering better value. Addressing each link of the value chain, this series has offered radiologists practical ideas and solutions to reengineer their workflow toward the emerging value-based delivery systems. In this final article, we discuss metrics and data necessary to monitor performance in the new outcomeand value-driven domain and outline how such business intelligence can inform strategy, design, and implementation of Imaging 3.0. IT is fundamental to driving this agenda, and the advent of big data and future trends are explored. In the current fee-for-service environment, performance metrics focus mainly on processes and inputs, which are financial (eg, revenue, expenses, days in accounts receivable), productivity-based (eg, examination

Perspectives on the Value of Advanced Medical Imaging: A National Survey of Primary Care Physicians

Abstract: Purpose To understand perceptions of primary care physicians (PCPs) about the value of advanced medical imaging. Methods A national quantitative survey of 500 PCPs was conducted using an online self-administered questionnaire. Questions focused on advanced medical imaging (CT, MRI, and PET) and its perceived impact on the delivery of patient care. Responses were stratified by physician demographics. Results Large majorities of the PCPs indicated that advanced imaging increases their diagnostic confidence (441; 88%); provides data not otherwise available (451; 90%); permits better clinical decision making (440; 88%); increases confidence in treatment choices (438; 88%), and shortens time to definitive diagnosis (430; 86%]). Most (424; 85%) believe that patient care would be negatively affected without access to advanced imaging. PCPs whose clinical careers predated the proliferation of advanced imaging modalities (>20 years of practice) assigned higher value to advanced imaging on several dimensions compared with younger physicians whose training overlapped widespread technology availability. Conclusions By a variety of metrics, large majorities of PCPs believe that advanced medical imaging provides considerable value to patient care. Those whose careers predated the widespread availability of advanced imaging tended to associate it with even higher value.

Modality Access: Strategies for Optimizing Throughput

Abstract: INTRODUCTION In our initial “Imaging Value Chain” series, we outlined the drivers, imperatives, and opportunities to reengineer the radiology workflow to one that delivers greater safety, quality, and patient satisfaction. In this follow-up series, we attempt to offer more concrete and specific recommendations to radiologists seeking to achieve that goal. In this fourth article of the present series, we strive to offer practical strategies to expand and expedite patient access to highefixed cost imaging modalities—mainly CT, MRI, and CT/PET—in both the inpatient and outpatient settings. This discussion assumes that the examination request is appropriate and concordant with ACR guidelines, an assumption unlikely to represent reality in day-to-day clinical practice because up to 30% of requested examinations are considered by some to be inappropriate. Advice to markedly improve appropriateness, however, was offered in the second article in this series. Assuming that appropriateness has been confirmed—indicating a real need for imaging to inform the next steps in a patient’s diagnosis and/or treatment—it behooves the radiology department to perform that examination as quickly as possible. Understandably, some examination requests will still require modification or cancelation for a variety of reasons (eg, patient contraindications), but

Imaging Appropriateness and Implementation of Clinical Decision Support

Abstract: The Institute of Medicine has estimated that 30% of all dollars spent on United States health care are wasted [1]. Although imaging’s contribution to that waste is difficult to pinpoint, most sources agree that inappropriate imaging is both widespread and commonplace [2]. Every inappropriate imaging examination places unnecessary, unwanted upward pressure on total health care system costs. From a system perspective, those unnecessary costs, both direct and indirect, are incurred in scheduling, protocoling, performing, monitoring, interpreting, and communicating examinations. From a clinical and quality perspective, patients can be harmed. Any imaging examination can be stressful, so an inappropriate one unnecessarily burdens the patient with anxiety, especially when associated with an access delay. The examination itself can be uncomfortable or incur risk (albeit small) from radiation and/ or contrast media. Importantly, inappropriate examinations displace necessary ones, delaying diagnoses and subsequent treatments for more needy patients. In an era of higher deductibles and copayments, this translates into ever increasing upfront costs to patients. In short, inappropriate examinations add no value to the system, only costs. Fee-for-service reimbursement systems, however, provide few incentives

Social Media and Public Outreach: A Physician Primer.

Abstract: The emergence of social media with easy and anywhere smartphone access has facilitated our society's information-craving behaviors to the point that many rely on the Web and social media to make health-related decisions. Recognizing this reality, many health care professionals and organizations have

The Challenges in Delivering the Value Chain

Abstract: medicine, such reports will be mined for data to identify subpopulations of patients with similar imaging findings that can be used to improve diagnoses and treatments. As a response to these articles, however, a number of radiologists are asking how better value can be delivered in actual practice, as it has neither a clear definition nor a roadmap for its successful delivery. Thus, early feedback suggests that even progressive practices are confronted with numerous challenges as they attempt to move from a volume to a value mind-set and delivery model. A desire has therefore surfaced for more meaningful direction, and better insight into what challenges radiologists may confront for themselves, their group, and their organization, as they move into this value paradigm. In this second set of 6 articles, we therefore set forth with a goal of addressing the challenges facing radiologists and their organizations as they attempt to re-engineer the imaging workflow based on the principles already highlighted. In the process, we hope to offer tactics as to how to effectively overcome some of these obstacles. This first article outlines the general challenges facing radiologists, and subsequent articles offer management and leadership insight as to how these obstacles