Considering Appropriateness, Dose to Improve Patient Experience

At conferences or departmental meetings, you’ve likely noticed a recurring subject: improving patient experience. It’s a hot trend in radiology, and some in the industry believe making it a reality takes more than better imaging machines.

In the age of healthcare reform, boosting patient satisfaction with the services you provide is critical to reimbursement. Many of you have purchased open or wide-bore MRI machines with higher Tesla strength to make your claustrophobic patients more comfortable. Or maybe you’ve added a scanner just for children. But your imaging technology is only part of the fix, according to some in the industry.

Ultimately, you should question every study you’re asked to perform.

“We know in the United States that 25 to 30 percent of radiology studies are done inappropriately without a good clinical reason,” said Stephen Herman, MD, president of MedCurrent, a Los Angeles-based radiology decision support consulting firm. “Either patients are demanding studies or doctors are practicing defensive medicine. The fact is there’s overutilization, but there are ways to avoid that.”

Getting the Test Right

Many factors go into selecting the correct diagnostic test - concerns over dosage, desires for good image quality, and deliberations about the best modality. For primary care providers who aren’t privy to ongoing best-practice conversations, ordering the best test for their patient isn’t always easy.

This is where a clinical decision support system (CDS) can play a role.
If a referring physician orders the wrong diagnostic test based on a patient’s history and current condition, a CDS can compare the order to existing benchmark data and suggest a more appropriate study. Not only does it eliminate the need for a radiologist to conduct multiple studies, but it’s also courteous to the patient, said Herman, who’s company manufactures the OrderRight™ CDS system.

“If a physician orders the incorrect imaging scan, the patient has to take more time to come back in, pay another co-pay, and potentially deal with the inconvenience for rescheduling other activities,” he said. “Most importantly, however, having to return to have the right test done will result in an avoidable delay in patient care.”

In fact, according to a January Journal of the American College of Radiology study, radiologists at the Virginia Mason Medical Center in Seattle ordered 39 percent fewer unnecessary CT and MRI scans for patients after implementing a CDS.

“The use of such systems can aid the elimination of unnecessary imaging, increasing both patient safety and quality,” wrote Virginia Mason radiologist Charles Blackmore, MD, MPH.

Conducting the right test the first time also reduces a patient’s exposure to radiation. Limiting dosage can be particularly important with patients who must undergo routine scanning and are concerned about the long-term effects.

In addition, a CDS can also satisfy the preauthorization requirement many insurance companies impose for diagnostic tests, truncating the time a patient waits for a study. The system can send the physician order electronically to a radiology benefits management firm for approval to receive a faster response than through other methods.

Know the Exposure

Finding the formula that produces the right balance between image quality and dosage for each protocol can be a struggle. In many cases, said Gregory Couch, president of Toronto-based Radimetrics, a firm that produces eXposure™ dose-tracking tool, radiologists receive little feedback on the radiation they’re giving patients even when they’re trying to provide low-dose services.

“When I talk with radiologists, many are alarmed to see the doses they’re delivering to patients,” said Couch, whose product integrates with the PACS/RIS system to store long-term data about patient exposure. Couch said the information they receive is based on parameters that quantify the output from the scanner, rather than the dose the patient received. Further, in some cases different measurements are used for different parts of the exam, making it decision making difficult.

In its Aug. 24, 2011 Sentinel Event, the Joint Commission echoed Couch’s call for increased attention to dose levels, supporting patient safety and training programs that give radiologists and technologists guidance on keeping dose levels low. The Commission also endorsed a national registry to track dose levels and use the data to identify optimal dosages for future scans.

To control patient exposure - and potentially reduce the possibility of future cancers - Couch said you must keep track of individual patients’ exposure over time, as well as track your protocols. With this information, you can examine how the dosages correlate to image quality and modify the protocols as needed.

Making sure your technologists are thoroughly versed in the protocols for all your scans can also enhance your patient’s experience. Most imaging mistakes or accidents are associated with the protocol, and a knowledgeable technologist can catch problems and work through them while limiting any negative impact on the patient.

However, you, as the radiologist, cannot be solely responsible for improving a patient’s experience. To make the enhancements to your patient’s time with you long-standing, you’ll need buy-in from all the providers associated with ordering and conducting a diagnostic test.

“Decreasing dose and improving a patient’s experience involves everyone,” Couch said. “It takes the referring physician, the radiologist, the technologist, and the medical physicist to work together to achieve diagnostic quality imaging with minimum risk to the patient.”