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July/August 2013
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ACR Task Force on Teleradiology Publishes New Practice Guidelines

 

Recently the American College of Radiology’s teleradiology task force published a report with best practice guidelines in the Journal of the American College of Radiology. Intended to engage all of the organization’s membership, the report addressed both the drawbacks and potential benefits that the practice of remote image interpretation offers to patients. “An important virtue of teleradiology is that many smaller hospitals that struggle to maintain adequate off-hour and subspecialty coverage can rapidly provide high-quality interpretations around the clock,” the authors said. Despite these benefits, task force members emphasize throughout the report that onsite radiology is preferred, and that teleradiology would optimally be offered as a component of a robust, locally based radiology service. (The report is available for download at www.jacr.org/article/S1546-1440(13)00185-3/abstract).

Comprised of eight radiologists and three non-physician experts, all members of the task force have had varying degrees of involvement in teleradiology and most physician members have a remote interpretation component integrated into their current practice. When asked about their assertion that onsite radiology is best, task force chair Dr. Ezequiel Silva III explained,

The task force did not commend nor condemn the practice of teleradiology. Rather, we approached this as an objective exercise to create standards for a growing radiology practice model. The task force did acknowledge several potential positives including the potential for improved sub-specialty, vacation/off hours, and small /rural facility coverage. We could not, however, recommend that teleradiology as the sole model of coverage is in the best interest of most facilities. Rather, teleradiology should complement a strong on-site presence performing the many activities we list in the paper such as protocoling studies, supervising contrast, and interacting with the medical staff routinely.

National teleradiology provider Virtual Radiologic (vRad) has always self-identified its role as adjunctive to local onsite radiology, but their Chief Medical Officer Benjamin Strong rejects the notion that their teleradiology service is inherently less accountable.

Although our general role may be supplemental, we view our responsibilities to our patients to be the same as those of onsite organizations. Our primary focus has always been on providing the highest quality care for the patient. I would have liked to see mention of the quality improvements that our model enables us to offer, including rigorous screening of radiologists and ongoing performance assessments. For example, we administer a clinical skills exam, apply intensive data analytics, and conduct ongoing peer review so as to insure that we hire and retain radiologists that are focused on patient outcomes.”

Whether images are interpreted remotely or onsite, the ACR’s report underscores the importance of ensuring that all business decisions in radiology be driven by what’s best for patients. The same standards for credentialing, report turnaround time, and communication should be enforced for groups reading onsite or remotely. All radiologists should also participate in quality improvement initiatives such as radiation dose reduction and peer review. ARIS Teleradiology, an Ohio-based national radiology group owned jointly by Summa Health System and a private equity company, is leveraging its hospital affiliation to embed quality into daily operations. The group utilizes Summa’s experienced credentialing team to evaluate and onboard its radiologists more efficiently. ARIS is also accredited by the Joint Commission to assure conformance to the highest quality standards.

When asked about the ACR’s position on teleradiologist participation in radiation dose reduction, Dr. Malay Mody, medical director for ARIS Teleradiology, explained the group’s approach:

Radiation dose reduction is accomplished in two ways. The first is the establishment of CT protocols that minimize dose and still provide diagnostic quality images; all ARIS clients have access to CT protocols developed in conjunction with Summa Health System. The second method of dose reduction is accomplished through the consultative process, which occurs between a referring physician and a radiologist prior to the exam being ordered. All ARIS onsite radiologists or teleradiologists are available to speak with a referring physician in order to discuss which test should be ordered to aid in the diagnosis and minimize exposure to radiation.

Another important element of performance for the teleradiologist is comparison of the current study to prior images. Teleradiologists frequently lack access to this pertinent medical information, which may lead to a less definitive interpretation or in some circumstances a completely erroneous diagnosis. Teleradiologists are not alone in this challenge; onsite radiologists often lack access to information on examinations performed at other institutions as well. The task force recommends continued focus on technology solutions to improve care coordination, including electronic medical record integration among disparate providers. Because Stage 2 Meaningful Use incentives will focus on improved health information exchange and clinical data sharing across multiple care settings it seems likely that better access to prior imaging studies is on the horizon for all types of radiology providers.

Perhaps the most challenging aspect of teleradiology practice is ensuring professional engagement between the distant radiologist and the local physician treating the patient. The report states, “An intangible benefit of the on-site practice component is that the physician is tied to the community, providing motivation to deliver a higher level of care.” The authors point out that as crucial members of the healthcare team, radiologists are obligated to provide much more than just a written report. They must also provide direction and education to technologists, who are required to perform under the supervision of a licensed physician in most circumstances. Dr. Strong indicates that vRad is addressing these and other communication needs through extensive use of support personnel and regular review of performance to guide improvement:

Our operations center is a technological marvel, with a dedicated and highly trained staff able to place critical finding calls, receive and direct clinical and protocol questions, and troubleshoot various issues with a minimum, of physician hold time and with a minimum of effort on the part of our radiologists. All interactions are digitally recorded and all service parameters are regularly scrutinized, resulting in robust documentation, constant improvement, and medicolegal protection for all involved parties.

Dr. Silva believes that radiology’s next move to improve quality must include greater focus on care coordination and the consultative role of the radiologist:

Radiologists should embrace a shift from volume to value. It is no longer sufficient to simply read studies, whether from teleradiology or locally. Radiologists should be involved across the entire spectrum of care. This involvement could start from the ordering of the study through decision support tools or direct physician consultation and continue through the communication of the results and participation in subsequent care. Future payment models appropriately link payment to quality, and all radiologists should strive to satisfy these quality standards, such as those incorporated in the Physician Quality Reporting System (PQRS).

Ultimately, the ACR cautions teleradiology providers and onsite radiology groups alike that the provision of safe, high quality services is imperative to remain competitive in the future:

First and foremost, radiology groups must understand that they create opportunity for competitors when they fail to satisfy the legitimate demands and expectations of their hospitals. Failure to provide rapid turnaround, subspecialty interpretations, or adequate coverage can force hospitals to consider alternatives.

Teri Yates is the founder and principal consultant for Accountable Radiology Advisors, a healthcare consulting practice that specializes in advancing the delivery of radiology services. She may be contacted at teriyates@accountableradiologyadvisors.com.

References
Silva, E., Breslau, J., Barr, R. M., Liebscher, L. A., Bohl, M., Hoffman, T, Boland, G. W. L., et al. (2013, May 20). ACR white paper on teleradiology practice: A report from the Task Force on Teleradiology Practice. Journal of the American College of Radiology, 10.1016/j.jacr.2013.03.018.

Webcast Available

In June 2013, author Teri Yates hosted a webcast on the topic of how radiology providers can transform their service to be successful under risk-based payment models, which includes improved quality and safety as well as better care coordination. The session is available online at www.accountableradiologyadvisors.com/continuing-education and is approved for CE credit by the ASRT.

Joint Commission and PCPI Recommend Strategies to Minimize Overuse of Five Treatments
Appropriate use will improve quality and safety of patient care.

America’s top healthcare experts are recommending a series of specific strategies to reduce five medical interventions or treatments that are commonly used but not always necessary.

In a paper released by The Joint Commission and the American Medical Association-Convened Physician Consortium for Performance Improvement® (PCPI®), advisory panel work groups offer approaches to address the overuse of

  • antibiotics for viral upper respiratory infections (URIs),
  • over-transfusion of red blood cells (called appropriate blood management for purposes of the summit),
  • tympanostomy tubes for middle ear effusion of brief duration,
  • early-term non-medically indicated elective delivery, and
  • elective percutaneous coronary intervention (PCI).

Overuse has been described as the provision of medical interventions or treatments that provide zero or negligible benefit to patients, potentially exposing them to the risk of harm. Sometimes overlooked or neglected as a leading contributor to problems with quality and patient safety, overuse of these medical treatments and interventions affects millions of patients. Overuse also drives up healthcare costs, with an estimated $1 billion spent annually on unnecessary antibiotics for adults with viral upper respiratory infections alone.

The paper, Proceedings from the National Summit on Overuse, provides detailed recommendations on curbing overuse of the five identified medical interventions or treatments, as well as an overview of the 2012 National Summit on Overuse that brought together representatives from 112 professional organizations and associations. The five advisory panel work groups that tackled the five areas of overuse are suggesting common strategies to inspire physician leadership, support a culture of safety and mindfulness, promote further patient education, remove incentives that encourage overuse, encourage further study and spur other professional organizations to collaboratively address overuse.

The advisory panel work groups are also recommending steps specific to each of the five areas targeted for reduction. Among the recommendations are:
Antibiotic use for viral upper respiratory infections: Develop clinical definitions for viral and bacterial upper respiratory infections, align current national guidelines that are contradictory, partner with the U.S. Centers for Disease Control and Prevention (CDC), and initiate a national education campaign on overuse of antibiotics for viral upper respiratory infections.

  • Appropriate blood management: Develop a tool kit of clinical education materials for doctors, expand education on transfusion avoidance and appropriate alternatives to transfusion, and develop a separate informed consent process for transfusion that communicates the risks and benefits.
  • Tympanostomy tubes for middle ear effusion of brief duration: Develop performance measures for appropriate use of tympanostomy tubes, determine the frequency with which tympanostomy tubes are performed for inappropriate indications in otherwise healthy children, and focus national research on issues related to tympanostomy tubes, including the role of shared decision making with parents and other caregivers.
  • Early-term non-medically indicated elective delivery: Standardize how gestational age is calculated, make the early elective deliveries indications and exclusion list as comprehensive as possible to improve clinical practice, and, educate patients and doctors about the risks of non-medically indicated early elective deliveries.
  • Elective percutaneous coronary intervention: Encourage standardized reporting in the catheterization and interventional procedures report, encourage standardized analysis/interpretation of non-invasive testing for ischemia, focus on informed consent and promote patient knowledge/understanding of the benefits/risks of PCI, and provide public and professional education.

“Overuse is a serious problem that involves many complex decisions between doctors and patients,” said Mark R. Chassin, MD, FACP, MPP, MPH, president and CEO, The Joint Commission. “The recommendations from the summit will raise awareness that will help both doctors and patients make better decisions going forward, and ultimately improve quality and patient safety.”

“The AMA is committed to improving health outcomes; this important work will help healthcare professionals ensure that the right patient gets the right treatment at the right time,” said AMA President Ardis D. Hoven, MD “As part of our strategic focus on improving health outcomes, one of our goals is to contribute to the appropriate use of finite healthcare resources and this will help us achieve that goal.”

Proceedings from the National Summit on Overuse is available at http://www.jointcommission.org/overuse_summit.

National Partnership Solicits Applications for Clinical Trial to Study Fall Prevention

As the next step in a partnership with the Patient-Centered Outcomes Research Institute (PCORI), the National Institute on Aging, part of the National Institutes of Health, has issued a Request for Applications (RFA) for a large-scale, multi-pronged clinical trial on prevention of fall-related injuries in non-institutionalized older adults. PCORI will commit up to $30 million to fund the trial selected through the application and peer-review process that NIA will administer. The application is available at http://grants.nih.gov/grants/guide/rfa-files/RFA-AG-14-009.html.

The RFA arose from an agreement by the two institutes announced in June to form the “Falls Injuries Prevention Partnership,” which focuses on a common, serious health concern for older individuals, their families, and their clinicians. Falls frequently result in serious injuries that can lead to loss of function and independence. Older people who have previously suffered a fall have a significant risk of falling again. Patients, caregivers, and clinicians all want to know the best ways to address this problem, but there is uncertainty about the best prevention strategies.

As detailed in the RFA, applications must describe a clinical trial that will assess a multifactorial strategy for fall-related injury prevention that will include identification of high-risk individuals, assessment of their specific risk factors, and selection and assessment of interventions that address these factors.

Applications also must spell out how they will actively involve patients, family caregivers, healthcare professionals, and other stakeholders in the design and conduct of the trial and sharing of its results. These criteria fulfill PCORI’s mission of supporting research guided by those who need and will be most directly affected by study results.
Prospective applicants can find full details of the criteria, submission policies, and instructions in the RFA available on the NIH Guide for Grants and Contracts. Proposals are due Wednesday, Nov. 13.

The question of what strategies or combination of strategies work best for patients with specific risk factors for fall-related injuries rose to a priority level for PCORI based on extensive input the institute received from patients, caregivers, health care providers, payers, and other stakeholders, noted PCORI Executive Director Joe Selby, MD, MPH.

“The Falls Injuries Prevention Partnership combines the strengths of both institutes,” Selby said. “We’re pleased to have the benefit of NIA’s extensive expertise in conditions affecting older individuals as well as its established infrastructure and capabilities in managing large, multi-year clinical trials in this effort to facilitate patient-centered research on a serious problem that affects millions of older individuals and their families.”

“Serious injuries from falls, such as broken bones or traumatic brain injury, are a major reason for the loss of independence among older people,” said NIA Director Richard J. Hodes, MD. “This is a significant public health problem, greatly affecting older adults and their families as well as the health care system. The clinical trial envisioned here seeks to test a comprehensive and practical approach that can make real progress in reducing these injuries.”

The Falls Injuries Prevention Partnership is among the first initiatives to result from PCORI’s effort to craft funding announcements focused on specific, high-impact research topics. PCORI identified an initial set of these topics by reviewing previous efforts to identify and prioritize gaps in comparative effectiveness research and then empaneling expert, multi-stakeholder workgroups to help refine the list.

Medically Induced Trauma Support Services

Sixth Annual MITSS HOPE Award

Nominations are due by September 13.

MITSS (Medically Induced Trauma Support Services) is accepting nominations for the annual HOPE Award, which recognizes individuals and organizations that exemplify the mission of MITSS, to Support Healing and Restore Hope to anyone impacted by medical errors or adverse events. The award is open to patients, families, healthcare providers, hospitals (or teams or departments therein), academic institutions, community health centers, grass roots organizations, EAP programs, and others.

The HOPE Award was established in 2008 by the MITSS Community Outreach Committee and is being sponsored by RL Solutions. The winner will receive a cash prize of $5,000 to continue their important work.

Nominations are due by Friday, Sept. 13. The award will be presented at the MITSS 12th Annual Dinner and Fundraiser to be held on Thursday, Nov. 14, at the Westin Copley Place Hotel in Boston. Eligibility criteria and submission requirements, nomination forms, and a listing of past winners are available at www.mitsshopeaward.org.