Applied Radiology

Dr. Lewis is the Chairman and Founder and Dr. Schilling is the CEO and President of MedOrder, Inc., Seattle, WA. Dr. Schilling is also a General Partner with Mi3 Venture Capital and a member of the Editorial Board of this journal.

The Order Loop is defined as the pathway linking the referring physician to a center for patient transaction (eg, radiology, laboratory, pharmacy, etc.) and the return of patient information (eg, reports, images) to the referring physician. The Order-Loop ^TM defines healthcare delivery with 4 billion orders per year. (The term "Order Loop" has been filed as a registered trademark by MedOrder, Inc., Seattle, WA. The term as trademarked is a description or concept tied to MedOrder's medical software and services.)

Every medical process is an order-result (Order-Loop ^TM ). The medical record is a collection of Order-Loops such as laboratory, radiology, visits notes, prescriptions, consultations, and surgery reports. Automation of the Order-Loop produces a horizontal integration across vertical systems, transforming healthcare, just as Enterprise Resource Planning and Materials Resource Planning solutions have transformed manufacturing. These processes have allowed companies to innovate new successful business models.

Healthcare industry trends of falling connectivity costs and increasing e-commerce capabilities, such as "Web Services," will facilitate the adoption of workflow automation in healthcare. The Order-Loop is expected to play a key role in this exciting change in healthcare.

Orders represent the currency of healthcare. Up to 80% of healthcare costs are in the orders. The order-results process is therefore the key healthcare delivery process, requiring automation in order to lower transaction costs while improving service. The present situation in healthcare can be characterized as an explosion in medical information and regulations. This is increasing costs and worker stress, which leads to widespread institution financial stress. The healthcare system is in a crisis!

The Internet promise to improve healthcare (e-health) is widely accepted, yet remains unfulfilled. The Internet is a necessary tool but is insufficient by itself to transform the industry. Web automation of broken processes is not transforming. Transformation requires a visionary approach to bridge existing structural barriers.

What are the existing barriers?

* Healthcare delivery is a distributed, mostly manual process, transcending multiple boundaries among patients, physicians, institutions, and payers.

* 25% of all healthcare costs are consumed in the existing paper-fax-phone communication process. At least 30% of orders contain errors or major deficiencies. Information transmission, management, and retrieval is inefficient and error prone.

* Rising regulatory burdens of coding, compliance, and documentation are overwhelming healthcare workers.

* Existing software solutions are inward (vertical) business-focused versus outward (distributed) medical-communication focused.

* Existing manual workflow processes poorly bridge the vertical islands of medical automation.

* Multiple information retrievals are required to reconstruct a "medical" picture from transactions.

* A Unified Medical Portal Interface to medical information is required to simplify retrieval and information representation.

This article will address a graphical user interface (the Anatomic Navigator, MedOrder, Inc.) that targets the need for a unified medical portal interface. Medical thinking, training, and treatments are organized around physiology and anatomy. For example, medical specialists follow this pattern: cardiologist, urologist, neurologist, pulmonary, endocrine, etc. Existing systems categorize information by business categories (radiology, laboratory, pharmacy, hospital), rather than medical categories (gastrointestinal, heart, urinary, endocrine). The Anatomic Navigator facilitates navigation and display by medical as well as traditional business categories. This results in efficient, "organized," medically meaningful information access.

To insure that the Anatomic Navigator effectively meets the needs of the customer, a strategic thinking tool known as the HIGH 5 will be described. ¹

Strategic thinking tools

Thinking and planning are activities that we perform every day. The sequence in which we complete our thinking and planning steps is an important factor in achieving maximum effectiveness. Ideally, we should devote an adequate amount of time to thinking about all sides of a particular problem before progressing too far with planning or implementing a solution. Many of us learn this lesson the hard way. We sometimes forge ahead with elaborately developed plans, without thinking enough about what we ultimately hope to achieve with our plans. We then have to go back to the beginning to rethink our options, before resuming the planning and implementation processes.

Strategic thinking tools (or frameworks) can be used to aid in the process of strategic thinking. One of the most attractive attributes of strategic thinking tools is that radiologists with various levels of business education and experience can use them. The tools are easy enough to be understood and applied by radiologists who have not had any formal business training.

The broad acceptance of these tools comes from the fact that they are easy to learn and highly effective. Essentially, this is because the tools communicate at a fundamental level between people. For example, in a regional healthcare community, where people possess diverse backgrounds, these tools enable the players to cross boundaries and relate effectively at a common, fundamental level.

A specific tool known as the HIGH 5 will be used to discuss the Anatomic Navigator approach to the Order Loop. The HIGH 5 is a tool or framework for thinking about the needs of the customer. The framework of the HIGH 5 is simply a set of five factors (which requires a selection process similar to that of the 80­20 rule -- 80% of the impact can be found in 20% of the factors). In a well-run organization or department, the HIGH 5 is the guiding focus for all personnel. In this manner, the organization never loses the focus of the customer.

The factors selected for the HIGH 5 should be based on a careful analysis of customer needs. This can be accomplished via surveys, interviews, focus groups, etc. It is important to periodically reassess the factors to constantly ensure that the clinical needs of the customer and the technical capabilities of the vendor are synchronized. This process is referred to as the clinical/ technical tie. The Anatomic Navigator HIGH 5 will present the clinical need. The Anatomic Navigator technology presents the technical solution required to meet the clinical need.

The clinical need

Reduction of workflow-driven costs is accomplished by reducing the number of steps, phone calls, and paperforms in the order process, thereby reducing ordering and results reporting costs. In addition, reduction of the downstream cost of claims processing is accomplished by providing automated coding at the point of order generation. The result is a reduction in the order process cost from $15 to $25 per order to $7 to $10.

Reducing errors is accomplished by providing access to guidelines, patient preparation instructions, and contraindication notices automatically, all of which reduce order-related errors. Errors in the coding necessary for reimbursement are reduced from 25% to 30% to <2%.

Improved information access is accomplished with the use of an image-based browser that speeds up the medical ordering and results reporting process. The browser provides intuitive point-and-click access to critical clinical and administrative information. For example, retrieval of radiology exam guidelines from the ACR is reduced from 2 minutes per exam to <10 seconds.

Improved regulatory compliance is accomplished through the automatic generation of the correct ICD-9 codes, improving ICD-9 to CPT code matching, assuring electronic signature of changed orders, and identifying and creating appropriate ABNs automatically. In addition, a secure message structure ensures compliance with the new HIPAA rules.

Enhanced revenues are accomplished by: flagging ABNs at the point-of-order, which improves Medicare reimbursements; providing improved coding; and being online at all times, thereby reducing the chance of missing orders.

Benefits from using tools

There are a number of benefits of using strategic thinking tools. In a given application of strategic thinking tools, some of the benefits will be more significant than others. However, it is important to review all of the benefits to make sure that the users are getting the most utilization that they can for any given application. The benefits described below are characterized in terms of the HIGH 5 tool.

Developing a common framework for solving problems

The HIGH 5 provides a framework in the form of a selection of the most critical factors required to serve the needs of the customer. It has been found that five factors is often the right number.

Identifying a common language for addressing problems

The language consists of the HIGH 5 and the meaning behind the selection process. This tool addresses a specific type of problem where customer satisfaction is key to the solution. Whenever a similar problem needs a solution, the team can revert back to the HIGH 5 tool for implementing the solution.

Thinking with simultaneous focus and flexibility

Focus is derived by having a framework. However, in establishing the content (eg, the details of the five factors), there is flexibility for individual input as team consensus is developed.

Stimulating creativity in problem resolution

The creative process is derived from having a team brainstorm the content within the framework. The developmental process for arriving at the final set of five factors is up to the creativity of the team.

Communicating by asking the right questions to find the right answers

The question raised by the HIGH 5 tool is: What are the needs of the customer? After considering an array of possibilities, the question focuses on how to combine and prioritize factors to achieve the final five factors.

Promoting teamwork in problem solving

Teamwork is established as the process moves from individual input to consensus of the final result. All of the benefits of using tools are enhanced by the use of teams wherever possible.

Establishing team confidence in the problem solving approach

Confidence is achieved as the consensus process is carried out. The utilization of a framework is essential to organize individual inputs into a consensus.

Building a foundation for future problem solving

As situations change (eg, technology, clinical service, or socioeconomic changes) an update of the HIGH 5 becomes appropriate. The foundation established in creating the initial HIGH 5 makes this an efficient and effective process.

Providing outlines for planning

Strategic thinking with the use of tools promotes "doing the right things." Planning, the process of "doing things right" follows. The establishment of the HIGH 5 represents "doing the right things." The details of how each of the five factors is carried out represents "doing things right."

Focus on customer satisfaction

A meaningful team activity should always focus on the customer. The customer can be thought of as someone receiving a service or as management receiving results. The development and execution of the HIGH 5, as described above, fundamentally ensures that customer satisfaction is brought to fruition.

The technical solution

The clinical problem is shown in Figure 1. The practice of medicine is based on anatomy and physiology. This is the way in which physicians are taught to think. This model of medicine is consistent for all the disciplines that apply to medicine, including diagnosis, treatment, examinations, education, training, and specialization. Therefore, it follows that any parallel system for orders and other areas of business transactions would follow the same model of medicine. Unfortunately, this has not been so, prior to Anatomic Navigation.

Instead, a healthcare information model that treats business transactions as independent inputs is presently being used. Areas of transactions treated in this manner include order codes, laboratory information, billing, radiology information, medications, etc. It is the disconnection created by conflicting models (the medical model opposed to the healthcare information model) that has resulted in the cost, error, access, compliance, and revenue challenges outlined above.

Conversion of information between the two models is cumbersome, costly and error prone. It is estimated that the information transformation process consumes 20% to 30% of a physician's time. ² The technical solution is shown in Figure 2.

The solution to the dilemma presented above is to use a single model for both medicine- and business-related entries. With the use of an Anatomic Navigator (driven by an anatomic information model) medical intuitive views of information remove the disconnection between the conflicting models described above. Medical intuitive views of information can improve the order process by intuitively constraining and simplifying the available codes to a given medical problem. It is evident that a medical interface is needed to bridge between the medical and business needs. The order results process is the ideal workflow point to streamline both the medical and business tasks associated with healthcare. AR