1 The Clinical NeuroradiologistSukhwinder Johnny Singh Sandhu, M.D. May 18, 2017

2 Disclosures No financial disclosures Member of ACRAlternate councilor on board of FRS directors

3 Outline Role of the radiologist Utilization A new subspecialty?

4 Objectives Review radiology’s traditional roleRealize changes in payment models Aware of clinical decision support software Encourage a clinical approach

5 Outline Role of the radiologist Utilization A new subspecialty?

6 Historical role of the radiologist

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8 Workflow Physician order Case protocoled and exam performedPhysical films kept in reading room Images interpreted and report transcribed Transcribed report is signed Ordering physician provides results

9 Radiology rounds Team comes to reading room Discussion of patientInteraction between radiologist and clinician Action items generated Learn from each other

10 Payment model Fee for service Technical and professional feesEat what you kill

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12 Current practice and trends on the horizon

13 Workflow Physician order Insurance authorizationCase protocoled with possible re-auth Exam performed and available on PACS Radiologist generates a report Physician provides results Patient may not realize radiologist involved

14 Timeliness Time is essential Many physicians read on their ownLook at the impression Agree or disagree Look at the interpreter Ignore or pursue

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16 Issues with reports Check list on everythingStructured reports: splitters vs. lumpers Dictation errors Patients read reports

17 Utility of RadiologistsMany specialists feel they can read as well Neurology boards We emphasize incidentals Neurosurgery ligamentous case Spend tremendous amount of time on non relevant details portrays us as “out of touch”

18 Clinician Radiology InteractionIncreased demand on radiologists Introduction of PACS Teleradiology services – commoditization Timely? Too little too late. The “Invisible” Radiologist

19 “The Invisible Radiologist”And there’s one other important loss in this period that’s often overlooked: When the images go digital, the radiologist’s work lists in their PACS becomes their main interface. It’s a powerful interface, but it’s not a particularly collaborative or patient-centric. And the face-to-face collaboration with the referring physician in the reading room largely goes away.

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21 Relevance If no-one reads my report, how can I be helpful?How can I provide an answer when I don’t even know the question?

22 Outline Role of the radiologist Utilization A new subspecialty?

23 Utilization Diagnostic imaging growth rates of 8% to 16% annuallyNew technologies (PET, MRA, CTA, etc.) Self-referral Patient demand Defensive medicine Don’t want to be wrong Unnecessary exposure to radiation Hospital inpatient and emergency departments experiencing the same trends as outpatient Costs

24 Utilization Control cost by cutting reimbursementCMS 12 cuts since 2005 Mandates on quality are coming Sustainable growth rate – “doc fix”

25 Centers for Medicare and Medicaid ServicesMedicare’s Request for Information on the Provisions in MACRA ACRONYM LIST APM: Alternative Payment Model, CAHPS: Consumer Assessment of Healthcare Providers and Systems, https://goo.gl/3Vp3tn CEHRT: Certified EHR Technologies, https://goo.gl/5NPu3c CHIP: The Children’s health Insurance Program, CMS: Centers for Medicare & Medicaid Services, https://goo.gl/xz31Re CNS: clinical nurse specialist, CQM: Clinical Quality Measures, https://goo.gl/n1bcHE CRNA: certified registered nurse anesthetist, EAPM (entity): Eligible Alternative Payment (entity) EHR: Electronic Health Records, EP: Eligible Professionals, https://goo.gl/4gN29t GPRO: Group Practice Reporting Option, https://goo.gl/0vG3aW HPSA: Health Professional Shortage Areas MACRA: Medicare Access and CHIP Reauthorization Act of 2015, https://goo.gl/3DASwD MAV: Measure-Applicability Validation, https://goo.gl/31AjWV MIPS: Merit-Based Incentive Payment System, MSPB: Medicare Spending Per Beneficiary, https://goo.gl/uYLGF3 MU: Meaningful Use, NP: nurse practitioner, NPI: National Provider Identifier, https://goo.gl/b20lRI ONC: Office of the National Coordinator of Health IT, https://www.healthit.gov/ PA: physician assistant, https://goo.gl/3tRhnS PFPM: Physician-Focused Payment Model, PFS: Physician Fee Schedule, https://goo.gl/NFjyUJ PQRS: Physician Quality Reporting System, QCDR: Qualified Clinical Data Registry, https://goo.gl/ot11cb QP: Qualified Practioner, https://goo.gl/jFcAf8 QRDA: Quality Reporting Document Architecture, https://goo.gl/fPu4pV RFI: Request for Information, https://goo.gl/jKUWsI SGR: Standard Growth Rate, TIN: Tax ID Number, VM (VBM): Value-Based Payment Modifier,

26 CMS APM: Alternative Payment ModelCHIP: The Children’s health Insurance Program MACRA: Medicare Access and CHIP Reauthorization Act of 2015 MIPS: Merit-Based Incentive Payment System SGR: Standard Growth Rate

27 It’s especially important to pay attention to ACRSelect since on April 1, 2014, President Obama signed H.R into law. This law mandates that: Starting on January 1, 2017 For all Medicare patients Physicians will only be paid for advanced imaging exams if the examination was ordered through an approved clinical decision support tool. For those who don’t use CDS, the alternative will be a new preauthorization process similar to what we have seen for years with private payers. There’s a lot more details in this bill which I won’t get into here. But if you want to learn more about this, I’d recommend checking out the ACR’s website. ** Of course, there will still be situations where the guidelines don’t provide clear cut guidance or the referring physician has concerns about the recommended course of action. In those cases, we believe that the referring physician should consult with a radiologist to determine the most appropriate course of action. To do this, we’ll need tools that support meeting scheduling, direct messaging and real-time conferencing. There are a few interesting side benefits of decision support: This decision making process can be documented in the EHR. That means when the evidence recommends against performing a test, that can be noted and provide a shield against the need to practice defensive medicine. Another benefit of this integration of the radiologists’ knowledge into the ordering process is that we can eliminate the need to have imaging studies preapproved by a RBM (Radiology Benefits Manager). This can save everyone time, effort and money. And it creates a more collaborative relationship between providers and payers.

28 What is quality? Has to be measurable. Structured reports.Dictation errors. Repeat scans. Radiation dosing. Adherence to appropriateness criteria.

29 MIPS Radiation documentation Carotid stenosisDocument search for priors Appropriate recommendations Pulmonary nodules Abdominal lesions Thyroid

30 Clinical decision support

31 History of ACR Appropriateness Criteria®Task Force formed late 1993 11 expert panels 9 diagnostic 2 therapeutic Criteria development over the last 20 years

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33 Imaging 3.0: Transitioning from Imaging 2.0 to Imaging 3.0Volume-based Value-based Transactional Consultative Radiologist centered Patient centered Interpretation focused Outcomes focused Commoditized Integral Invisible Accountable So there are a number of changes we’ll see in the Imaging 3.0 era. We’ll move from a volume-based model to a value-based one. We’ll have a return to consultative relationships. We’ll move from a radiologist-centric model to a patient-centric one. We’ll move our focus from image interpretation to patient outcomes And when we do all of this, we radiologists will change from being somewhat invisible to being accountable members of the healthcare delivery team. Obviously, this is a pretty tall order. So we’ve been developing a transition model that breaks down what needs to occur into three key areas: Changing the culture of radiologists and the rest of the system in terms of how they interact with us. Adopting new IT tools The alignment of incentives to support these changes In the rest of this presentation, I’m going to drill down in more detail about how we are executing in each of these areas. And I’ll also share some case studies of organizations that are making good headway in these areas.

34 Healthcare Delivery Lifecycle: OrderingNow, this content is integrated directly into an order entry system like EPIC or Cerner.

35 Case Study: Clinical Decision Support in Minnesota$200,000,000 in Savings 1Q03 2Q03 3Q03 4Q03 1Q04 2Q04 3Q04 4Q04 1Q05 2Q05 3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07 3Q07 4Q07 1Q08 2Q08 3Q08 4Q08 1Q09 2Q09 3Q09 4Q09 1Q10 2Q10 3Q10 4Q10 1Q11 2Q11 3Q11 4Q11 1Q12 25 30 35 40 45 50 55 60 HTDI Utilization Rate per 1,000 Members ACTUAL UTILIZATION PROJECTED UTILIZATION WITH AN UNMANAGED POPULATION PROJECTED UTILIZATION WITH DECISION SUPPORT The best known case study about the use of decision support for ordering diagnostic images is from Minnesota. This study was one of the key pieces of evidence that helped sway Congress and the President to sign this law. Back in 2006 they were projecting that by 2012 the MN imaging utilization rate was going to rise from just over 40 studies per 1000 members to almost 56 studies per (That’s the green line in this graph.) Instead, by implementing clinical decision support, this growth in the rate was largely halted. The yellow line in this graph was the revised projected growth with CDS. And the yearly actuals are the blue line. This has translated into a savings of over $200 million to payers and patients since the beginning of this intervention.

36 Potential Barriers to CDSNo one likes to click – hard stops May learn to work around How often do the clinicians include true history Physicians and people learn to navigate the system – dizziness and giddiness Communications with referring physicians

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38 Outline Role of the radiologist Utilization A new subspecialty?

39 The Clinical Neuroradiologist

40 Quality? Did I help the patient? Did I answer the question?Did I play a role in more timely treatment?

41 Role of the radiologistAnswer the question. Identify the question. Timely fashion – reports antiquated? If you don’t come to us …. Facilitate optimal patient care One specialty that touches almost all patients

42 Model of Clinical Neuroradiologist

43 Clinical NeuroradiologyCritical care and clinical pharmacists Don’t bill Decrease length of stay Prevent medical errors Dose antibiotics /oversee antimicrobial stewardship Therapeutic INR

44 Clinical NeuroradiologyDiagnostic neuroradiologists will continue Clinical neuroradiologist EMS Trauma Neurosurgery Neurology ENT and OMFS

45 Job description Assigned to a neuroscience ICU Round with teamShift responsibilities from diagnostic Manage stroke alerts

46 Model of Clinical NeuroradiologistReal time decision support ICU, ED and clinics before test is ordered Opportunity for patient interaction and satisfaction (HCAHPS scores) Knowledgeable of appropriateness criteria Familiar with treatment algorithms

47 Model of Clinical NeuroradiologistTumor boards M & M Conferences Multidisciplinary conferences Quality improvement

48 Real time reads Focused examReal time read with backup for incidentals Monitor discrepancies Doctor’s doctor as the ultimate consultant

49 Pilot programs Neuroscience ICUManage stroke alerts as quality project Multiple sclerosis clinics

50 Examples of interventionPrognosis end of life DAI Dissection case and anticoagulation Skull base tumor board and pituitary lesion Cerebellar bleed Dissection, M1 occlusion and free fluid Surgical planning System problems such as trauma recidivism

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72 Challenges and future directionHow to incorporate? Bill for consultation? Hospital pay for by recognizing cost savings?

73 Challenges and future directionCollect data. Show improved patient care. Cost avoidance. Diminish utilization. Decreased length of stay. Document change in management.

74 Other applications Patient consultation especially in tumor f/uTrauma and emergency departments Case management. Almost everyone comes through radiology. Global perspective on health problems. Root cause of trauma. Be problem solvers – clinical issues should drive imaging.

75 Advantages Improved patient care Visibility Patient interactionACR guidelines applied Stop the goose chase Patient and film continuity – “scanxiety” Decrease costs of un-necessary studies Decrease length of stay Relevance of the radiologists

76 “You must be the change you want to see in the world.”We must perform the clinical correlation we recommend.

77 References ANNE M. BOBB, BS PHARM, THOMAS H. PAYNE, MD, PETER A. GROSS, MD. Viewpoint: Controversies Surrounding Use of Order Sets for Clinical Decision Support in Computerized Provider Order Entry Journal of the American Medical Informatics Association Volume 14 Number 1 Jan / Feb Viewpoint Paper. Giles W. Boland, MDa, Lucille Glenn, MDb, Shlomit Goldberg-Stein, MDc,Saurabh Jha, MDd, Mark Mangano, MDe, Samir Patel, MD f, Kurt A. Schoppe, MD g, David Seidenwurm, MDh, John Lohnes, MDi, Ezequiel Silva III, MDj, Richard Abramson, MDk, Daniel J. Durand, MDl, Laura Pattie, MDm, Pamela Kassing, MDm, Richard E. Heller III, MDn v Report of the ACR’s Economics Committee on Value-Based Payment Models . J Am Coll Radiol 2017;14:6-14. Copyright ! 2016 American College of Radiology David W. Lee1 Richard Duszak, Jr.2 Danny R. Hughes2 Comparative Analysis of Medicare Spending for Medical Imaging: Sustained Dramatic Slowdown Compared With Other Services . AJR:201, December 2013 Bershow B, Courneya P and Vinz C. Decision-Support for More Appropriate Ordering of High-Tech Diagnostic Imaging Scans. ICSI Colloquium on Health Care Improvement, May 2009. https://www.acr.org https://www.icsi.org/_asset/0g594t/HTDI-Decision-Support-Overview.pdf Neiman Report is produced by the Harvey L. Neiman Health Policy Institute, Reston, VA. Cite as “Medical Imaging: Is the Growth Boom Over? e Neiman Report, No. 1, October 2012.” Andrew J. Gunn, MD Mark D. Mangano, MD Garry Choy, MD DushyantV. Sahani, MD Rethinking the Role of the Radiol- ogist: Enhancing Visibility through Both Traditional and Nontradi- tional Reporting Practices1 RadioGraphics 2015; 35:416–423 How to take action against radiology threats: Part 1 By Kate Madden Yee, AuntMinnie.com staff writer Copyright © 2013 AuntMinnie.com Last Updated np 2/6/2013 2:23:27 PM

78 Thank you!