Ideas for Hospitals, Centers and Practices

Goodbye RBM, Hello ROE-DS?
Developing World To Receive Imaging Support
Texas Facility Transformed by EHR

Goodbye RBM, Hello ROE-DS?

With the Obama budget proposal, getting a preapproval from a radiology benefits manager may become a Medicare mandate. But is there a better way to screen for unnecessary imaging exams?

There is hope for radiologists and physicians aggravated by the red tape and inconsistencies of radiology benefit management (RBM) systems used by insurance carriers to reduce the number of medically unnecessary imaging exams.

Instead of the traditional—and some might say capricious—RBM phone approval model, vendors are developing computer-based radiology decision support (DS) software systems that bypass the call centers and allow physicians to directly order exams using evidence-based computer algorithms. The question for insurers is “Will these systems stem the growth of imaging exams?” The answer appears to be yes.

A 7-year study conducted at Massachusetts General Hospital (MGH) using RadPort, a radiology order entry (ROE) and DS product developed by Burlington, Mass-based Nuance Communications, has shown a dramatic decrease in the growth rate of some imaging exams, particularly in CT and ultrasound.

RadPort and similar systems could eventually change the current RBM paradigm, saving time and reducing unnecessary exams, while more quickly and accurately providing the most appropriate exams to patients.

The MGH Study

When physicians at MGH were faced with a major insurer wanting to implement an RBM, the head of the hospital’s physicians group, Jeffrey B. Weilburg, MD, sought an Internet data input alternative that would score exams based on the appropriateness criteria developed by the American College of Radiology (ACR). MGH and the insurer agreed—in return for the physicians group accepting pay for performance targets for their imaging utilization.

Weilburg asked Keith J. Dreyer, DO, PhD, to develop an order entry system using ACR appropriateness criteria, which became the basis for the RadPort product.

With the Nuance ROE and DS system, a referring physician logs onto a secure server and enters the patient’s symptoms and the requested imaging exam, history, and other requested information, mostly with check boxes. The Internet-based system immediately responds with an appropriateness score of 1 to 9 with 9 being most appropriate based on the ACR guidelines. Scores are also color coded. If the DS system gives a 1 to 3 “red” score, it then suggests another exam based on ACR criteria, but, unlike an RBM, does not force the physician to choose that exam. Instead, it allows the original exam, but the physician must input an explanation why the choice was made. Then the exam—or the newly suggested exam—is immediately approved and can be ordered. The patient can get an appointment immediately, and the outpatient center has its preauthorization code.

Modules are also available where physicians and administrators can review their “red” rate of overrides compared to peers.

To measure the effectiveness of the ROE with DS system, Christopher Sistrom, MD, MPH, associate professor of radiology and associate chair for radiology informatics at the University of Florida, Gainesville, along with Weilburg, Dreyer, and other researchers, conducted a 7-year retrospective study of outpatient advanced imaging utilization before, during, and after the ROE with DS implementation.

The results of the study showed a significant decrease in the growth rate of CT, despite the increase in the number of patient visits during the same period.1 The authors report that on a yearly basis, the growth rates before and after ROE and DS system implementation were:

  • CT: 12% before, 1% after
  • MR: 12% before, 7% after
  • US: 9% before, 4% after

CT, one of the most expensive imaging exams, had the most impressive drop, but the researchers also were surprised by the ultrasound figure because physicians in the study were not given a DS score, but were merely asked to input the data for their request.

Sistrom attributes this to what he calls “the gatekeeper effect.” He explained, “In the old days, people ordered tests by faxing or telephone or telling the nurse to get this test. Now the doctors are encouraged to log on themselves and order the test. So I think, even though we weren’t giving these [US] scores, there was still a different way for you to order the test.” Consequently, theorizes Sistrom, the new mode of ordering encouraged physicians to reevaluate or educate themselves as they were ordering.

Other Advantages of ROE with DS System

While the RBM call-in model is also a gatekeeper system, many physicians are burdened by dealing with the wait time, lay customer service personnel, and varying approvals.

Sistrom said, “One of the criticisms of RBMs is that you’re working with different representatives who are working with different scripts and books, and you get different answers each time.” With an ROE with DS system, said Sistrom, the score is consistent, but also respects the doctor and the patient if they still want to get the test, so long as the explanation is noted.

A further advantage is that the ROE with DS system is instant. While a patient is waiting outside, the physician can input the required information on a laptop and receive a score, then change the exam if needed, and immediately give the patient authorization to schedule the exam.

It will be up to the insurance carriers whether RadPort or any decision support system will be adopted in lieu of a call-in/fax-in RBM system. Nuance reports that its solution is less expensive than RBMs and will still effectively decrease unnecessary imaging.

With the Obama Administration’s goal of reducing imaging utilization costs by $70 million over 5 years, CMS is considering implementing an RBM. However, Sistrom reports that CMS is also considering their solution.

—Tor Valenza


  1. Sistrom CL, Dang PA, Weilburg JB, et al. Effect of computerized order entry with integrated decision support on the growth of outpatient procedure volumes: seven-year time series analysis. Radiology. 2009;251:147-155.

Developing World To Receive Imaging Support

According to the World Health Organization (WHO), two-thirds of the world’s population is without access to basic diagnostic medical imaging services. WHO further estimates that there is a need for one diagnostic imaging machine for every 50,000 people. Now the World Health Imaging Alliance (WHIA) has announced that it is taking steps to remedy this situation.

WHIA is a nonprofit medical imaging solutions provider that leverages vendor, NGO, and academic relationships to deliver low-cost, diagnostic tools to underserved communities around the world. Their goal is to aid in the deployment of 20,000 systems worldwide, providing up to1 billion people with access to diagnostic imaging.

WHIA intends to fulfill its vision by providing a complete, low-cost, sustainable digital imaging solution. Although many of today’s providers can bring low-cost solutions to developing countries, most have been ineffective at creating sustainability. As a result, less than half of the approximately 1,500 WHO-approved, installed x-ray systems are in operation today. In addition, many solutions miss capabilities such as clinical site needs assessment, image storage, teleradiology, and remote monitoring—all of which WHIA can provide for enhanced sustainability of an imaging clinic.

In order to provide a complete solution, WHIA has developed partner relationships with key vendors. For example, Sedecal, a global OEM manufacturer of x-ray systems, has partnered with WHIA to provide WHO-approved x-ray machines at a discounted cost. Digital medical imaging is provided through a relationship with Carestream Health, a global company providing medical and dental imaging systems and information technology. As Diana Nole, president, digital medical solutions, Carestream Health, points out, “The availability of even just a few high-quality imaging systems can help improve the health of thousands of people in the impoverished regions of the world.”

The software systems that manage the digital images have been provided through a partnership with Merge Healthcare, a leading medical imaging software solutions company. According to Justin Dearborn, CEO of Merge Healthcare, “We are delighted to provide this to WHIA as well as to work together on the broader vision of providing diagnosis and data anywhere in the world.”

WHIA also partners with the academic community. “By establishing close ties to the local universities, we’ve significantly increased the odds of a successful implementation and sustainability of these clinics,” said Matt Glucksberg, professor and chair of Biomedical Engineering, McCormick School of Engineering, Northwestern University. “Local universities serve as an anchor for WHIA’s efforts and an ongoing resource for the clinics.”

WHIA has established a site in South Africa and another is being implemented in Guatemala. Close relationships with the Rotary International and local organizations have provided WHIA with a lineup of candidate sites interested in receiving its contributions. In addition, WHIA has established relationships with many of the global not-for-profit organizations involved in providing imaging services.

“WHIA has a great model for delivering leading edge diagnostic tools to developing markets, but that is just the beginning,” said Ivy Walker, WHIA’s CEO. “Our efforts in data compilation can create a platform that can be used to develop improved tools for computer-assisted diagnosis and public health data analysis. Ongoing partner and solution development under this model will continue to move WHIA toward this vision.”

—James Markland

Texas Facility Transformed by EHR

Since the implementation of Medsphere’s OpenVista electronic health record (EHR), Midland Memorial Hospital (MMH) in Midland, Tex, has realized a host of improved clinical results, including fewer patient deaths and medical errors and decreased infection rates, as confirmed by an independent case study.

Midland Memorial is a 320-licensed bed hospital, operating on two campuses. The facility provides a full range of acute care services through a team that includes 800 clinical staff, 200 physicians, and 300 auxiliary personnel. Owned and operated by Midland County Hospital District, MMH also serves as a regional referral center for other communities throughout west Texas and southeast New Mexico. Specialty services include emergency medicine, general/vascular surgery, cardiovascular care, and advanced radiological and oncology services.

The 2008 study was initiated by Medsphere to evaluate the effectiveness of OpenVista and was conducted by a third-party organization without Medsphere involvement. The study shows Medsphere’s solution has converted the Texas hospital into a secure, paper-lite facility through improved patient care and clinical decision support.

David Whiles, director of information systems for Midland Memorial Hospital, said, “The system provides a great deal of benefits. For instance, it’s very intuitive. We have universal access. It only takes a couple of hours’ training for users to come up to speed.”

OpenVista is now in use by all MMH health care workers to access patient information. Statistics from the study confirm that the solution has enabled clinical transformation through better decision-making and patient care processes.

Among the direct benefits of OpenVista revealed in the study were that patient deaths declined by roughly two persons per month and deaths among heart attack patients declined 27%, in part through electronic alerts ensuring timely preventive health measures. Central line bloodstream infection rates declined by almost 88%, and inconsistencies associated with medication administration fell from more than 33% to about 13%.

With OpenVista, almost 100% of physicians now enter orders electronically; Midland staff can access patient records instantaneously, and clinicians can access the same data remotely and securely.

“Without question, OpenVista has helped Midland Memorial Hospital take the lead in affordable health information technology,” said Russell Meyers, CEO of the hospital. “Both health care for our patients and the decision-making process for our staff have improved. Midland Memorial is very proud of what the partnership with Medsphere has enabled us to accomplish.”

Impact on Radiology

OpenVista has had a positive impact on all departments, including radiology. “It speeds up charting significantly,” said Whiles. “The output is totally legible. Considering the typical doctor’s writing, you know how important that is. In the end, the system delivers an enormous increase in efficiency.”

According to the study, chart availability helps everyone to fulfill their roles and allows for simultaneous access to the same record by different roles. Medication verification can now be conducted in a more timely fashion due to the ability to better allocate pharmacist coverage for this function. And information availability on outpatients and emergency department patients has helped radiology staff preplan interventions and improve continuity of care. In conclusion, time spent reviewing records is now quicker, resulting in faster resolution of patient complaints.

Importantly, the study’s findings at MMH also support what health care IT advocacy groups are saying about the value of EHRs like OpenVista. The Healthcare Information and Management Systems Society (HIMSS) Analytics organization last year recognized Midland as a Stage 6 health care facility—the highest level of automation recognized by HIMSS to date. The designation by HIMSS Analytics recognizes facilities that have implemented health care IT solutions and achieved established levels of automated patient care and clinical process improvement. With OpenVista, MMH was able to achieve Stage 6 for about one-third the cost ($7 million versus an average of $22 million) and in less than half the time (3 years versus 7 years) required by other vendors whose clients earned Stage 6 status.

—J. Markland