“Building Collaborations to Improve Imaging Utilization” was the theme of a special session organized by radiologists and held June 13 at the American Medical Association (AMA) Annual Meeting in Chicago to encourage delegates to participate in the American College of Radiology’s Radiology Support, Communication and Alignment Network (R-SCANTM).
Marc H. Willis, D.O., associate chairman for quality improvement at Baylor College of Medicine, Houston, and Jacqueline A. Bello, MD, professor of clinical radiology at Albert Einstein College of Medicine, New York City, spoke during the hour-long session. They described the costs of inappropriate medical imaging, the quality improvements possible through R-SCAN, the mechanics of R-SCAN itself and the shared experience of clinicians and radiologists who use the program to introduce clinical decision support (CDS) and Choosing Wisely® principles to their hospitals and clinics.
The ACR was awarded a $2.9 million grant by the Department of Health and Human Services in September 2015 under the Transforming Clinical Practice Initiative (TCPI) to support a transformation of physician practices towards value-based reimbursement through R-SCAN.
The ACR is collaborating with the AMA, another TCPi grantee, on several educational fronts. R-SCAN educational resources feature two modules from the AMA’s STEPS Forward project, a broad-based effort to enhance patient experiences, improve population health, lower health care costs and boost physician professional satisfaction. Additionally, the two societies are collaborating on a STEPS Forward co-branded CDS educational activity, offering free CME that is expected to be available early fall 2016, Willis said.
R-SCAN aims at enrolling 4,000 radiologists and 20,000 referring clinicians in the next several years to improve imaging appropriateness and efficiency of image ordering. With more than 70 radiology practices on board, the program is close to achieving 50 percent of its radiologists’ recruitment goal. Radiology practices carrying out R-SCAN are engaging referring clinicians and have nearly achieved a year-one milestone of signing on referring practices representing 5,000 referring colleagues.
To assure success, R-SCAN requires referring clinicians and radiologists to work together to use CDS and clinical recommendations from the Choosing Wisely® campaign, developed by the American Board of Internal Medicine (ABIM), Willis explained. Following a prescribed educational programs, they can substantially reduce the kind of overutilization that led 72 percent of physicians in a 2014 Robert Wood Johnson Foundation/ABIM study to admit they knowingly ordered at least one unnecessary test a week, including advanced diagnostic imaging. Half of the physicians said they ordered unnecessary tests to avoid malpractice claims.
“R-SCAN lowers barriers to quality improvement in daily practice.” Willis said. “It provides a template and all the educational resources that radiologists and their ordering providers need to initiate this process.”
R-SCAN participation is free. Downloadable educational materials include step-by-step guides, a growing list of Choosing Wisely topics and complementary access to ACR Select®, a CDS system offering an electronically consumable version of the ACR Appropriateness Criteria®.
The educational component of R-SCAN invites participating clinician teams to design a customized educational program using resources from the ACR and other professional medical organizations, Willis said. The appropriateness of imaging utilization is rated before and after the education program. Participants will soon have access to Radiology-TEACHES, an interactive simulation case module.
ACR Select CDS is used to rate the appropriateness of imaging exams ordered, and the data are used to create quantitative reports. Choosing Wisely Topics cover various specialties, including cardiac imaging, chest imaging, genitourinary imaging, musculoskeletal imaging and neuroimaging.
To illustrate how R-SCAN works, Willis described its application at Baylor to improve the appropriateness of CT pulmonary embolism (PE) protocol utilization in the emergency department. A baseline analysis of 100 cases with CDS revealed that 25 percent of the referrals for PE computed tomography (CT) were inappropriate.
As part of the team focused on improving performance, Willis worked with the team leader L. Alexandre R. Frigini, MD, director of quality control, and Shkelzen Hoxhaj, MD, MPH, chief of emergency medicine, to facilitate the project. A one-hour Emergency Medicine Grand Rounds involved a summary of the baseline study results, a lecture on the Choosing Wisely campaign, a video on the ACR Appropriateness Criteria and a presentation by Hoxhaj on the Society of Emergency Medicine PE guidelines.
“His commitment to collaborate with us was critical to our success,” Willis said.
A follow-up evaluation involving a CDS analysis of 100 new cases was performed six weeks later. Results indicated a significant improvement, with the rate of inappropriate PE CTs falling to 12 percent, though untapped opportunities for future continuous quality improvement remained.
Radiologists and ordering clinicians benefit in at least two ways by participating in R-SCAN, Willis said. The collaborative nature of R-SCAN builds interpersonal relationships leading to a more professional and collegial clinical environment. And, it serves as the starting point towards a culture of collaborative practice improvement.
“Everyone wins, if we can improve patient outcomes and do things more appropriately and at a lower cost,” Willis said.
Radiologists and referring clinicians can learn more about R-SCAN or register to participate at the R-SCAN website.