News Story

Governance, Mission, Growth

Service with a Signal: Order Decision Support
Electronic Tools for Doctors, Staff, and Patients
Practices Praise Benefits of Image-Guided Treatment

Service with a Signal: Order Decision Support

In 2006, the Minnesota state legislature passed a law requiring that all insurance carriers with a client base that included Medicaid implement a preauthorization system or clinically developed decision support system. The payors responded in 2007 by implementing prenotification programs through radiology benefits managers prior to paying for the services of Minnesota health care providers. What’s an imaging practice to do?

Suburban Imaging, an affiliate of Suburban Radiologic Consultants Ltd, Minneapolis, installed the RadPort imaging order decision support application from Commissure Inc, New York. Built on appropriateness criteria developed by the American College of Radiology (ACR), Reston, Va, the RadPort suite combines multimedia reports distribution with clinically advanced decision support.

Mary Ellen Kerber, director of marketing for Suburban Imaging, explained, “Three insurance companies in Minnesota implemented physician support for high-tech imaging, and we wanted to offer this service to our clinics as a timesaver for them. Because we can schedule the examinations for the patients, and also perform the decision support at the time of scheduling, it saves the clinics from having to make a second phone call to get the same outcome. And this was okayed by the payors before we began. They gave us permission to offer this service to our clinics.”

RadPort is configured around a scheduling center. Referring physicians and referring physician staff call into the center, and information is entered into RadPort, where appropriateness is scored automatically based on a series of questions.

“The response to it has been very positive,” noted Kerber. “The system is quite intuitive. It just makes sense. When you’re going through scheduling for a certain exam, the questions it asks you are pertinent to that exam.”

Kerber explains that appropriateness is scored according to color, and the colors correspond with traffic signals. “Green means it’s good to go,” she said. “Yellow means caution, which means we schedule it and have a nurse call the ordering physician’s nurse. If it gets a red, we slow down and have a radiologist look over it and gather more information, and then the doctor and the radiologists together determine the appropriateness.”

This type of evaluation is vital in Minnesota, where some form of review of appropriateness is now required by law. But even in states where decision support is not mandatory, as payors become increasingly aware of how the high price of advancing imaging services contributes to escalating health care costs, automated ordering guidance is useful in evading hassles from insurers and limiting low-utility testing. RadPort also tracks ordering patterns for individual physicians, for subspecialty groups, and on a modality/anatomy basis, making utilization management easier.

“Every morning, our radiologists would protocol each exam, and if something seemed unnecessary or inappropriate, the radiologists called the physician,” Kerber said of Suburban’s previous process for order decision support. “Now we have essentially the same process, but the difference is really the time on the front end. We’re very happy with the software, and it’s a great service we can offer the clinics.”

—Cat Vasko

Practices Praise Benefits of Image-Guided Treatment

Even before the code specific to image-guided radiotherapy (IGRT) was instituted, MIMA Cancer Center, part of Melbourne Internal Medicine Associates of Melbourne, Fla, was already performing the cutting-edge treatment. Its radiation oncologists had been administering IGRT soon after the center opened in 2003.

Todd Scarbrough, MD, director of the Cancer Center at Melbourne Internal Medical Associates, and Joseph Ting, MD, chief medical physicist, rely on Varian technology for IGRT.

“We thought it was in the patient’s best interest to provide a higher level of targeting accuracy,” said Nanialei Golden, the center’s director of radiosurgery. “Through IGRT, we have been able to tighten the treatment margin around a target, escalate the dose, and spare more normal tissue. We have seen a decrease in radiation side effects.”

Prior to the advent of advances in IGRT, radiation oncologists were challenged with variations in patient position and respiratory motion, forcing the physicians to treat a larger margin of healthy tissue around a tumor. With IGRT, doctors can minimize the volume of exposed healthy tissue and potentially identify changes in tumor shape and size over a course of treatment.

In the summer of 2006, the center purchased Varian’s Trilogy System for IGRT and stereotactic applications. The company’s Clinac iX linear accelerator was retrofitted in 2005, along with Varian’s OnBoard Imager device for generating high-resolution radiographic, fluoroscopic, and cone-beam CT images at the treatment machine.

Compared to hospitals, practices have a significant benefit when it comes to offering IGRT in their facilities.

“The advantage is that we tend to look at the economics and the utility of the new technology acquisition in a relatively quick way, and if it makes sense, implement without a lot of committees helping us make the decision,” said Chris M. Rose, MD, chief technology officer for Vantage Oncology of Beverly Hills, Calif. “Also, for now, it appears that the packaging of the image guidance reimbursement in the daily treatment charge within the Hospital Outpatient Prospective Payment System will add a disincentive to obtaining this technology within a hospital.”

Rose, whose practice also uses Varian’s technology, said eventually physicians and administrators will have to calculate the cost of delivering a course of therapy and the aggregate of the codes that can be charged.

In the case of Rose’s practice, the therapy is almost all reimbursable; however, he is not sure whether this is because the facility looks to be selective in administering treatment and refrains from doing it every day, or whether it is because payors are notified in advance. Vantage Oncology has experienced a 1% ultimate payment dial rate, with codes often kicked back for explanation—though no more than other new technologies, he continued. “Every so often, we have to ‘eat’ the charge,” Rose admitted. “I do not like it, but if the guidance is necessary, then it has to be done.”

Both Rose and Golden pointed out that the primary downside to the therapy is increased treatment time that must be budgeted, in addition to manpower issues. In order to ensure success of the advanced tech-nology, training is imperative. “The chief therapist worked very hard to make sure that all of the therapists were comfortable with actually creating the images,” Rose said. “For me, there was a need to accelerate the learning curve of the therapists in terms of their understanding of cross-sectional anatomy for the cone-beam machine.” Ultimately, though, IGRT is a tremendous benefit to the patient, and these minor setbacks are immaterial, they asserted.

Moreover, Golden and Rose believe that IGRT technology will continue to improve, allowing radiation oncologists to quickly change the shape of targeting on the fly, rather than going back after treatment to make modifications. The ability for instantaneous, real-time reshaping of the radiation beam represents IGRT’s future, both said, and it is already headed in that direction.

“These are the sorts of developments and synergies that excite me and cause me to think that the future will be very interesting,” Rose said.

—Elaine Sanchez