Published on the Dec. 19, 2013 Rheumatology Network website
By Whitney L.J. Howell
Healthcare reform implementation is in full swing. How will it affect rheumatologists? Questions remain, but industry experts say that much of the impact lies with rheumatologists themselves.
The specialty has already faced one healthcare delivery re-design: In the 1990s, health maintenance organizations (HMOs) proved disastrous for providers and facilities. Now, in similarly-designed accountable care organizations (ACO) touted under the Affordable Care Act, providers are assigned to share responsibility and payments for patient care.
For some, ACOs may conjure the ghosts of failed collaborative-care efforts under HMOs. But experts say that rheumatology’s response has been largely positive.
“Rheumatologists are more hopeful now,” said Rod Hochman MD, president and CEO of Providence Health & Services in Seattle. “There are lessons learned from the HMO experience. We know rheumatologists must ensure the healthcare system knows what they do and how they affect change.”
In fact, according to the 2013 Medscape Rheumatologist Compensation Report, 23% of rheumatologists have participated in ACOs.
Preparing For Success
While positive attitudes will help during this transition, Hochman’s biggest concern is whether rheumatologists can educate their physician-colleagues about the impact of rheumatology services. Succeeding, he said, means demonstrating how rheumatology simultaneously improves patient care and controls costs.
“Rheumatologists must position themselves as musculoskeletal managers,” he said. “They’re uniquely situated to understand what’s needed or not and what therapies are possible, particularly with joint and back pain, before going for surgery.”
It’s crucial for rheumatologists to assume this role because musculoskeletal services often rank among a facility’s top five service lines, accounting for significant expenditures.
For example, rheumatologists can increase collaborations with orthopedists and neurosurgeons to determine whether a patient needs surgery. Or they can partner with primary clinicians to diagnose many causes of joint pain without extensive and expensive imaging studies.
With cost control as a bedrock ACO principle, concerns exist within rheumatology that hospital-provider relationships could shrink. Instead of partnering with practices, some providers fear, facilities will opt for a single part-time rheumatologist to treat patients. Some evidence supports this concern – more than 80% rheumatologist providers spend fewer than four hours weekly treating inpatients, according to the Medscape report.
But Hochman believes relatively low numbers and skill-set specificity will protect rheumatologists.
“There will be few rheumatologists nationwide, so there shouldn’t be a big worry about being out of work. The focus should be maximizing abilities and relevance,” he said. “Understanding inflammatory disease is invaluable, so it isn’t a question of not working. It’s of getting reimbursed for work they do.”
Recouping adequate payment in ACOs could prove difficult because rheumatologist-managed conditions, including joint pain or knee and hip replacements, face bundling.
“It’s going to be tricky as we go to bundled-episode payments from fee-for-service,” Hochman said. “Under fee-for-service, rheumatology has been predominantly outpatient, so things can’t get worse. They can only get better.”
He recommended that providers closely monitor reimbursement for biologic agents used to treat rheumatoid arthritis and other autoimmune conditions, as well as infusion therapy payments.
The American College of Rheumatology (ACR) is more wary of bundled payments, however. In a Nov. 12 letter to the U.S. Senate Finance Ways & Means Committee, the ACR expressed concern over the potential long-term impact.
“Bundled payments under one label or another will drive providers to identify patients with the best margins,” the ACR wrote. “This will result overall in less value and even worse access for the patients.”
Consequently, Hochman said, providers should discuss with payers how they’ll handle reimbursement and care management in ACOs. Based on Medscape report data, nearly 40% of rheumatologists would drop poorly-reimbursing payers.
Healthcare attorney Stephen M. Harris, a member of the Knapp, Petersen, Clarke firm in Glendale CA, advised rheumatologists to determine whether participating in a Medicare ACO – which often uses primary services for patient assignment – prevents them from participating in others.
There are two ways to avoid this problem, he said:
- Bill under a separate federal tax ID number (TIN): Provide some services under professional services or employee leasing agreements with facilities billing under their TIN. Or form a separate group that retains and bills for physicians or lets providers work part-time elsewhere. Physicians could also bill under their Social Security numbers.
- Code differently: Select codes not categorized with primary care services. For example, code office visits as part of a global procedure fee. Beware, though: This method could limit reimbursement.
Ultimately, Hochman said, rheumatologists must integrate into care management in a way that avoids being seen as part of primary care.
“Rheumatologists will be teachers and managers of patient populations in ACOs,” Hochman said. “If I formed an ACO, I would ensure leadership had a couple of rheumatologists to manage the system and work with primary doctors.”
To read this article at its original location: http://www.rheumatologynetwork.com/articles/surviving-aca-guide-rheumatologists
Published on the June 4, 2013 DiagnosticImaging.com website
By Whitney L.J. Howell
When it comes to the implementation of new technologies,, radiology is considered a leader among medical specialties. True-to-form, the industry is now on the leading edge of employing electronic medical records (EMRs), as practitioners move to take advantage of federal incentives in the meaningful use program. Despite their tendency to be tech-savvy, radiologists still could use some guidance for successful EMR implementation, a topic of an expert panel at this year’s Society for Imaging Informatics in Medicine (SIIM) annual meeting.
The panel plans to focus on what radiology practices and departments can do survive and facilitate the implementation process. And, according to participants, there are strategies you can employ to stream-line these efforts.
“Because of the need to maintain and work with RIS and PACS systems, there has been a long-standing relationship between radiology and the information technology offices,” said Jim Turnbull, chief information officer for the University of Utah Hospitals and Clinics. “These groups have worked closely together, and there aren’t any surprises anymore. But as we continue to move forward with EMRs, there are still things people should keep in mind.”
1. Get Buy-In: The most important step in properly putting your EMR in place is ensuring your facility’s governance supports the project from the top down. It’s critical to making sure the set-up goes as smoothly as possible.
“You don’t want to be part way into EMR implementation and have people start second-guessing everything and saying that it’s too expensive,” Turnbull said. “It’s a lot more costly to change direction.”
It’s possible to avoid stumbling blocks by working with human resources staff to design a detailed strategic plan, he said.
2. Form a Diversified Team: Even though radiology is one of the most tech-savvy specialties, effective EMR implementation will require several outside partnerships.
The most successful teams include representatives from the emergency department, nursing, pharmacy, IT, labs, and other specialties, according to Julie Riddler, the project manager for implementing the Epic EMR at The Johns Hopkins Hospital. It can also be helpful for project leaders to participate in other hospital committees, such as ambulatory, inpatient, and physician steering teams.
3. Prepare for the Long-Term: As complicated as correctly implementing an EMR can be, it isn’t the end of the process, Turnbull said. There will always been a need for maintenance or a new way to maximize what your system can offer.
“Optimization continues forever,” he said. “The key is establishing a mindset in the office culture that you can’t just plug the EMR in and let it be. This type of system never works that way. The practice or department must be onboard with consistently trying to make things better.”
Conducting a needs assessment prior to implementation can give you an idea of any future changes that might be required.
4. Invest in Personnel Training: Institutional support and identifying your organization’s needs can only take you so far. It’s also important to provide training for all staff and providers who will play a role in implementing and using the EMR.
To reach this goal at The Johns Hopkins Hospital, Riddler facilitated one-on-one and group coaching sessions on using the Epic EMR, as well as offered staff and leadership development curricula around key competencies. She also engaged professionals from other health systems to provide more extensive technical training.
Although other specialties are joining the push to implement EMR solutions, radiology still has the opportunity to maintain its leadership position, Turnbull said, through proper and thorough planning.
“The big challenge will always be making sure you’re putting the networks in place to manage the huge image movement around your organization,” Turnbull said. “But if practices and departments work hard to provide an environment of partnership, then the implementation situation will be workable.”
To read the article at its original location: http://www.diagnosticimaging.com/pacs-and-informatics/4-tips-emr-implementation-success#sthash.KoKwwoPC.dpuf
Published on the April 18, 2013, DiagnosticImaging.com website
By Whitney L.J. Howell
As implementation of the Affordable Care Act continues, all sectors of the healthcare industry are being called upon to increasingly rein in costs. For many insurance providers, patient steerage has proven to be an effective strategy. But the impact on radiology has been largely negative, industry experts said.
Patient steerage in radiology occurs when outside forces — usually insurance providers — actively direct patients or physicians to lower-cost radiology practices. And, this strategy is becoming more prevalent nationwide, said Geraldine McGinty, MD, chair of the American College of Radiology’s (ACR) Commission on Economics.
“Our feeling is that as radiology benefit managers have maxed out on the initial imaging volume savings they can offer to clients, so they’ve started participating in programs to drive patients to facilities where the payers have negotiated lower reimbursement rates,” she said. “Recently, it’s been more aggressive due to increasing involvement of patients as they take on more responsibility for their care through higher-deductible plans.”
In fact, according to an informal survey by the Radiology Business Management Association (RBMA) in September 2012, 65 percent of respondents reported experiencing active patient steerage from either radiology business management (RBM) groups, payers, or both. With active steerage, payers give patients incentives, such as gift cards, for choosing lower-cost providers. In addition, 47 percent confirmed the presence of passive steerage — simply making cost differential data available to patients and providers.
However, patients are also driving a certain level of steerage. A recently-published joint ACR-RBMA paper credits high-deductible insurance plans and patient cost awareness with some patient redirection.
What Payers Are Doing
While not all payers have patient steerage programs, many do. For example, in September 2011, Anthem Blue Cross Blue Shield in Ohio implemented a steerage program for imaging services through which company representatives called patients in attempts to redirect them toward lower-cost providers. Within nine months, more than 3,500 patients had been called and steered to different imagers.
In addition, WellPoint launched a passive steerage campaign with OptiNet, an Internet portal through which referring physician were encouraged to schedule patients with lower-cost imagers. When referrers largely ignored this resource, however, WellPoint enlisted RBM company American Imaging Management (AIM) to call patients directly. According to AIM marketing director Ana Perez, nearly 20 percent of patients chose lower-cost imagers in response to the phone calls.
Other payers, such as UnitedHealthcare, also provide radiologist cost information, but they do not actively contact patients. Still other payers successfully steer patients by classifying certain providers as out-of-network in a patient’s insurance plan.
The Impact of Patient Steerage
The increasingly prevalence of patient steerage can potentially impact practices and departments on a variety of levels, McGinty said. According to the ACR-RBMA paper, she said, radiologists should be aware of the three main ways patient steerage can affect everyday practice.
1. Daily operations: When payers redirect patients, providers can lose any time they’ve already spent in the pre-authorization process. They can also experience productivity dips , and if they don’t know patients have been steered elsewhere, they could face vacant or missed appointment slots. Imagers could also be asked to answer patient and provider questions about any steerage and why it occurred. Overall, up to 82 percent of RBMA survey respondents indicated steerage decreased their patient volume. However, some respondents — about 14 percent — actually saw volume increases due to patient steerage.
“The big item will be the loss of business, and virtually every practice is looking at a decrease in volumes,” said David Levin, MD, a radiologist with the Center for Research on Utilization of Imaging Services at Thomas Jefferson University. “It’s not like in the early 2000s when volumes were growing like crazy and it wasn’t a problem if we lost a little business because insurance steered our patients elsewhere. No one feels that way anymore.”
2. Legal issues: When payers actively steer patients to lower-cost imaging centers and away from a referring physician’s initial suggestion, they open themselves up to potential medical liability if findings, such as a lung cancer, are missed. In addition, legal action can also be launched against the chosen imager, the imager’s corporation, and the RBM. It’s also possible, especially with active steerage, that these activities violate the federal anti-kickback law that forbids any payments or solicitations that influence patient health decisions.
According to the ACR-RBMA paper, radiologists could also assert payer-directed steerage impedes their legal right to practice, defames their professional reputations by listing them as lower-tiered providers, or violates any existing contracts they have with facilities to receive a certain amount of referrals.
3. Provider relationships: Any payer-directed steerage can disturb existing healthcare relationships, McGinty said. Referring physicians often have a small cadre of imaging providers, chosen for their levels of quality and service, to whom they send patients. Redirecting patients to different imagers can damage long-term provider partnerships and can impose on referrers the additional cost of transferring all patient records to a new imager. Any instances of incomplete reads prompt the need for a second radiological opinion. And, the radiologists providing the second read do not receive reimbursement.
Impact on Patients
While survey data exists to support the negative effect steerage has on providers, the verdict is out on how much payer redirection influences patient care.
The ACR’s biggest concern, McGinty said, is that steerage can confuse patients.
“Patients build relationships with their physicians over time, and they value their doctor’s advice and guidance,” she said. “We don’t want to see those relationships disrupted or see patients’ confidence shaken when it’s suggested they see an imager their doctor didn’t recommend.”
It’s also paramount, she said, to make it clear to patients that payer recommendations are only cost-based suggestions. Many patients are unaware they have a choice to simply pay a higher fee for seeing the imaging provider chosen by their referring physician.
Payer steerage also increases the risk that patients will be sent to a facility without ACR accreditation. But that risk is small, Levin said, adding that ACR accreditation ensures a certain level of service quality.
“I don’t think steerage will impact patient care that much. People will get scans if they need them even if insurance companies steer patients to places they think are more affordable,” he said. “It’s not as if there’s a huge variation in quality so that if you go to my hospital you’ll get a great scan, but if you go to the hospital down the street, you’ll get a lousy one.”
To read the remainder of the article at its original location: http://www.diagnosticimaging.com/practice-management/patient-steerage-could-harm-radiologists-confuse-patients
Published in the April 15, 2013, Raleigh News & Observer and the April 14, 2013, Charlotte Observer
By Whitney L.J. Howell
Swatting at pesky insects or air-borne particles – it’s a common, everyday activity for nearly all living creatures. It’s a way to keep clean and get rid of anything that might cause future problems.
But what about machines and vehicles that can’t take a swing at annoying parasites, particularly ones submerged in water?
Continual biofouling – the accumulation of microorganisms, plants, algae, or animals on wet surfaces – has been a long-term problem for the global shipping industry. Now researchers at Duke University’s Pratt School of Engineering have developed a strategy that could enable ships to rid themselves of creatures and substances that hitch a ride on their hulls.
Coating ships in a new material that shakes itself on command can eliminate several problems associated with keeping ships clean, said Xuanhe Zhao, a Duke mechanical engineering researcher.
“If you’ve ever seen a horse or cow shake its skin or tail to get rid of flies, that’s analogous to shaking off something that’s bugging the ship,” he said. “We’ve introduced a new mechanism that can deform, and that deformation can literally detach the biofouling materials adhering to the surface.”
Why slough the ships?
Apart from being unsightly, barnacles and other biofouling substances can inhibit a ship’s ability to function. Even a small amount can cause difficulties, said Gabriel López, a Duke biomedical and mechanical engineering professor. He is also the director of Research Triangle Materials Research Science and Engineering Center.
“Even a small layer of slime can significantly increase drag, and
as drag on the ship goes up, the fuel consumption goes up, as well,” he said. “Pollution goes up, and more greenhouse gases are produced.”
Leaving biofouling materials stuck to ships can also have another environmental impact. For ships sailing worldwide, there is a risk invasive species will be transferred from their native habitat to ones where they can be damaging. For example, nutrient-hoarding zebra mussels from Russia were brought via ship hull to the Great Lakes in the late 1990s. Within 10 years, these invaders had wreaked havoc on the region’s fishing industry and levied more than $3 billion in damages.
Ridding ships of biofouling materials is also of military import, López said. The more barnacles and bacteria a ship carries, the noisier the vessel is, making it easier to detect.
How it works
Traditionally, the shipping industry used less-than-optimal means to protect vessels. For more than 40 years, global maritime companies coated their roughly 30,000 ships with paint containing tributyltin, an inexpensive, effective – and poisonous – barnacle- and algae-killer. An international treaty banned its use in 2007.
Another protection method has been a polymer coating that reduces biofouling substances’ ability to adhere to the boat. It’s a temporary fix, though, because bacteria and barnacles eventually adapt to the polymer and attach themselves anyway, Zhao said.
This new solution, however, starts with an environmentally safe silicon rubber polymer coating on the ship’s hull. Running voltage through the flat polymer turns it into a capacitor – a passive structure that stores energy – and generates an electric field, he said. This cleaning strategy then relies on electrostriction, a property of electrical nonconductors that allows them to change shape when exposed to electricity, to slough away the offending substances.
“There are patterned channels – air channels – beneath the polymer, and if you blow air into the channels, it will increase the hydrostatic pressure and buckle up the polymer surface,” Zhao said. “We basically form a wrinkle on the surface of the polymer, and the biofouling substances simply detach.”
Although this strategy must be tested on the large scale, it does offer two advantages other cleaning solutions have lacked, Zhao said. The silicon rubber polymer could potentially last for years, and this method eliminates the need to dry dock a ship for cleaning. An electric current can be sent to the polymer anytime, anywhere, and the ship will slough off biofouling material.
Challenges, future uses
To date, Zhao and López have only tested this self-sloughing mechanism with areas only a few centimeters wide. But, according to Jan Genzer, a chemical and biomolecular engineer at North Carolina State, larger experiments are needed to prove it’s a valid cleaning solution.
“It’s a very clever, very different way to think about this problem – like trying to stand on a trampoline while it’s being shaken,” said Genzer, who created a different cleaning solution. “The real question is, though, can it be applied to a ship? How will the research translate to application? Will the discovery need to be modified?”
In his discovery, Genzer and his colleagues created a dense layer of molecules capable of repelling biofouling organisms by repeatedly hitting a stretched piece of rubber with reactive oxygen and allowing the rubber to rebound. The result, he said, was a roughness that helped prevent barnacle and algae accumulation.
Even though the self-sloughing mechanism has only been applied to shipping so far, both Zhao and Genzer agree that there are additional uses for this technology. Representatives from the food industry, lubrication companies, and medical device manufacturers have all expressed interest in this development, Zhao said.
“Any time you have synthetic material in contact with some sort of water that might have bacteria or other microorganisms in it, you will form this biofouling layer,” he said. “So, it’s a very pervasive problem.”
Ultimately, Genzer said, concentrating on strategies to remove biofouling materials rather than trying to create ones that prevent accumulation from even beginning will be a productive plan. Organisms adapt to survive when faced with foul-resistant substance, and that can do more harm than good to an ecosystem.
“People are now realizing foul-resistant coatings are more realistic. They allow deposits to settle, but they can be cleaned by shaking or running the ship at particular speeds,” Genzer said. “You can’t outsmart Mother Nature. She’s been around for millions of years, and she’s developed ways for organisms to survive in different conditions. If we can get surfaces clean, we should be happy, and leave it at that.”
Published on the April 8, 2013 DiagnosticImaging.com website
By Whitney L.J. Howell
Zero-footprint viewers. Vendor-neutral archives. Image mobility. Individually, they are helpful tools to radiology and becoming more ubiquitous. But together, they help create a cohesive enterprise imaging strategy.
Enterprise imaging (EI) isn’t a particularly new idea, but to date, it has been largely misunderstood, industry experts say. It’s more than simply implementing new technology. And, achieving the full benefits EI can provide will require both sophisticated software and provider engagement.
“Enterprise imaging is a hot topic, but there’s a big misconception around what we mean by it,” said Paul Chang, MD, University of Chicago School of Medicine’s enterprise imaging medical director. “Enterprise imaging is a much broader, more complex problem when you take the enterprise perspective rather than the silo perspective.”
What is EI?
Put simply, the goal of an EI strategy is to ensure the correct image is delivered to the right place at the appropriate time. It has the potential to fundamentally change how facilities, providers, and patients interact with diagnostic images. Reaching that goal, however, requires a great deal of collaboration, Chang said.
According to a 2012 KLAS report, many facilities are already moving in that direction. Of the 134 providers surveyed, most reported being in early EI stages. To create a fully integrated EI system, Chang said, these facilities and others must address five factors that affect how the healthcare system currently views and uses diagnostic images.
1. Archive architecture. For many providers, EI simply means implementing a vendor neutral archive (VNA), an archive-neutral vendor, or using a zero-footprint viewer, all methods for easily sharing images within the facility and off-site. However, the archive is only one part of a successful EI strategy, albeit an important component. It’s important, Chang said, to free radiology departments and practices from being tethered to one PACS, but identifying and employing an effective VNA is largely an IT responsibility.
“VNAs and zero-footprint viewers are just the middle wear that links commodity storage to the application layer,” he said. “We’ll do it, and we’ll go to the cloud. But it’s all buzzwords and plumbing. That’s designing the car. Now radiologists have to learn how to drive it.”
2. Multiple creators and consumers. Radiologists are no longer the only specialty that produces and uses diagnostic images. Today, cardiology, gastroenterology, pathology, and several other departments rely on imaging to provide proper patient care, so facilities must have a streamlined way to distribute scans throughout the health system.
“To do this right, you do need the architecture of a VNA or archive-neutral vendor, but there’s a bigger concept behind enterprise imaging,” Chang said. “This view is the realization of the modern enterprise that it must deal with both consumers and producers of images simultaneously throughout the hospital — not just radiology.”
3. Ubiquitous electronic health records (EHR). The concept of an EHR isn’t new to radiology, an industry that has used PACS and RIS for many years. But now, meaningful use requirements are calling upon the specialty to interface seamlessly with patients’ records through an entire health system. Consequently, according to KLAS imaging research director Ben Brown, all new systems must be interoperable. It will be up to a facility’s IT department, Brown said, to create an infrastructure that manages and stores PACS, maintain a patient index to ensure proper patient identification, and determine how long images are stored.
4. The enterprise concept. Years ago, when radiologists discussed “the enterprise,” the term referred to anyone outside the department who still worked within the hospital’s firewall. But as health systems have expanded and more specialties have become image producers and consumers, the definition of “enterprise” has expanded, Chang said. Radiology groups have consolidated, many facilities within the same system are separated by hundreds of miles, and providers are now required to read scans for multiple hospitals.
The logistics of moving images from one facility to another aren’t difficult — the real challenge comes in coordinating the workflow needed to properly use transferred scans. According to Rasu Shrestha, MD, MBA, a University of Pittsburg Medical Center radiologist, however, the potential exists, for EI to have a significant positive impact on work flow management.
“[EI] allows for a patient-centric approach to care versus an image- or application-centric approach,” he wrote in a 2012 Applied Radiology article. “It allows for the possibility of true collaboration among care teams, which would bring the value of imagers back into the spotlight.”
5. Tying it all together. The real challenge behind effective EI, Chang said, is to fuse the needed technology with the proper workflow perspectives. But it can be helpful, he said, to consider that EI is less about imaging and more about radiology’s need to re-invent itself as healthcare enters a new chapter of value-based purchasing.
“The concept of enterprise imaging is a proxy or code word for having to re-engineer a more useful, comprehensive workflow solution for a more complex enterprise,” he said. “It’s better not to talk about enterprise imaging but talk about re-engineering ourselves so we can continue to add value.”
How can you plan?
It’s no longer a question of whether EI is right for your practice or department. Radiology’s move toward EI is clear, and it’s up to you to determine how you will navigate these new waters. There are many moving parts with this imaging strategy, Chang said, but you can outline your course of action by remembering one question: “What is the role of radiology or the radiologist in this decision?”
For example, as the end-user, you can — and should —tell your IT department what you need out of a VNA, but don’t expect to be included in any purchasing decisions. The facility’s chief financial officer and chief information officer will make that determination, he said.
You will, however, have a greater role — alongside cardiologists and other providers — in determining how the VNA architecture will support your needs and workflow. In addition, you must make it clear to your hospital administrators and IT department that any EI system must offer interoperability for the strategy to succeed, said Robert Barr, MD, president of Mecklenburg Radiology Associates in Charlotte, N.C.
Through interoperability, he said, his practice — which has been using EI for several years — is able to quickly migrate images between all subspecialties, streamlining patient care and facilitating greater access to patient records.
Your biggest role, however, will be in providing evidence that supports the true value you bring to your facility. Your worth is no longer tied solely to the number of interpretations you produce daily, Chang said. You must now demonstrate your impact on patient outcomes, population management, and down-stream resource utilization and cost control.
“In the fee-for-service environment, we could be selfish and insular in our thinking. We floated everyone else’s boat,” he said. “But now we’re a cost center, and every CT you order better be worth it. Justify it, and demonstrate its positive impact.”
To read the remainder of the article at its original location: http://www.diagnosticimaging.com/enterprise-imaging-beyond-cloud-based-image-sharing/page/0/1