Dr. Blackmore is the Director of the Center for Health Services Research, Virginia Mason Medical Center, Seattle, WA; and Dr. Mecklenburg is the Medical Director, Center for Health Care Solutions, Virginia Mason Medical Center, Seattle, WA.
Healthcare costs continue to increase in the United States (U.S.),
consuming an ever-greater portion of the gross domestic product. Current
estimates are that >17% of the U.S. GDP goes to healthcare.1 This
is more than twice the developed country average of 8.3% and50%>
Switzerland, the next highest. In 2003, the World Health Organization
issued a report grading the quality of healthcare in different countries
around the world. The U.S. ranked 37th overall, ranking 47th in life
expectancy.2 This is worse than all of the Nordic countries and nearly all countries in Western Europe.
In a paper in the New England Journal of Medicine in
2010, Swenson and colleagues compared the current state of health-care
in the U.S. to manufacturing in the British Isles prior to the
industrial revolution.3 In effect, current healthcare is a
cottage industry with individual artisans providing customized care. The
system is fragmented, quality is variable, and variation is tremendous.
Data suggest that only 60% of the care for which there is strong
evidence is actually provided to patients in the U.S.4 In contrast, 20% or more of the care is unnecessary, adding cost and potentially causing detrimental outcomes.
is a strong contributor to increasing healthcare costs. The growth rate
of advanced imaging procedures exceeds that of medical cost increases
overall.5,6 Computed tomography (CT) is now the largest source of medical radiation and the most rapidly rising.7 Further,there is >50% variation in imaging rates between U.S. cities and regions.8
Increased awareness of radiation risk has led to increased
scrutiny,particularly of CT, with current estimates that inappropriate
utilization of this technology is on the order of 26%.9 The use of CT in the emergency department in particular is perceived as a major source of overutilization.
spiraling increase in imaging costs has caught the attention of
governmental and private payers. Federal healthcare reform efforts
include Centers for Medicare and Medicaid Services (CMS) demonstration
projects on strategies for controlling imaging utilization. Intervention
is also occurring at the state level. For example, Minnesota has joined
with the Institute for Clinical SystemsImprovement (ICSI) on a
statewide initiative to use a single vendor to provide imaging computer
decision support for all providers.10 A recent law in the
state of Washington provides for control of advanced imaging for
individuals covered by state health plans and determining the
feasibility of a single statewide solution for ensuring that advanced
imaging is used appropriately.11 Commercial insurance
companies have also taken an increasing interest in controlling advanced
imaging with preauthorization schemes proliferating throughout the
There are many good reasons for radiologists to improve
the appropriate use of imaging, including the moral imperative to be a
physician and to do no harm to patients; the business case for improved
quality; and the professional satisfaction of reading only studies that
add value.However, radiologists have traditionally served in a
consultative role regarding imaging appropriateness, and have not
necessarily positioned themselves to actively manage imaging. Further,
for all radiologists—but particularly for single specialty radiology
groups in private practice—optimizing the business performance of a
practice may conflict with limiting imaging to clearly appropriate
circumstances. Regardless, purchasers and health plans are clearly
taking an active hand in imaging management, and will continue to exert
more influence in the future. Less clear is whether radiologists and
other physicians will take the lead to manage imaging, or if physicians
will relinquish control over imaging to external entities.
objective of this paper is to introduce the choices and decisions that
providers must make to implement a system to ensure appropriate use of
imaging. Though radiologists may not be in a position to implement these
approaches unilaterally, they do need to understand the relative
tradeoffs to assume an active role in a decision-making process.
Different solutions may work better in different settings, and we
present the relative strengths and weaknesses of different approaches.
most important characteristic of an imaging utilization program is that
it be effective and efficient. The program should not introduce delays
in patient care. It should not add administrative costs for either
purchasers or providers. Additional desirable qualities,delineated by
Bernardy and colleagues, include that the system be prospective,
transparent, evidence based, and unobtrusive to the doctor-patient
relationship. Bernardy and colleagues also detail the value of a program
being both educational and supportive of continuing quality
improvement.12 Available imaging management solutions range
from preauthorization programs to point-of-order decision support to
post-procedure billing denial; they all have tradeoffs in all of the
Defining the key questions of timing
(point of control), extent (scope of control), and strength (degree of
control) can be used to illustrate the fit of a particular imaging
management approach to a given healthcare setting.
Point of control of imaging
noted above, there are choices regarding when imaging utilization
intervention can be performed (Table 1). Implementing controls prior to
imaging include traditional preauthorization programs where permission
from a third party is required before the study can be performed, as
well as precertification programs where notification that the study is
being performed must be provided to a third party, although actual
permission is not required. Such programs can be highly effective.
However, they lack the other desired characteristics. They are
obtrusive: An additional disruptive step is required.
denial of a preauthorization request potentially requires an extended
or repeat visit with the clinician. Preauthorization systems are not
efficient, as both the provider and the payer must hire staff to engage
in the discussion of whether the imaging is appropriate and provide the
necessary documentation. This decision-making process can consume
substantial staff time and is expensive for both payer and provider.
Preauthorization systems are seldom transparent, as they are usually
based on proprietary third-party appropriateness criteria,which may be
inconsistent across vendors. They may be evidence-based, but this can be
difficult to assess given the lack of transparency.In addition, these
systems are not educational, as the provider is generally not given an
explanation for why the study is considered inappropriate and what might
serve as an alternative. On the positive side, preauthorization
programs are fairly adaptable and easy to implement for health plans and
Imaging control can occur after the procedure has
been performed through denial of payment. Although the potential exists
for payers to save money, this is, in many respects, the least desirable
approach. Billing denial has no direct effect on unnecessary
irradiation of the patient, and the financial consequences are borne
either by providers who did not make the image ordering decision or by
the patients themselves. Systems based purely on billing denial are
often not transparent, are definitely intrusive, and are expensive and
inefficient given the often cumbersome appeals process. Consistency is
not guaranteed, as the criteria are not transparent and there is little
opportunity for education. They may have positive attributes of
adaptability and ease of integration with existing systems.
imaging control can also recur at the point of order, meaning that the
control step in determining whether imaging is appropriate occurs while
the physician is making the decision to order the study. Point-of-order
imaging management systems are generally built around clinical decision
support systems (Figure 1) that provide immediate feedback to clinicians
while ordering the examination. These prospective clinical decision
support systems have many ideal characteristics. They are usually
web-based or integrated into the institutional physician order entry
system, and are generally transparent; the provider is able to see the
imaging criteria when the order is being placed. They are performed at
the point of care and so are less obtrusive as well as substantially
less expensive than preauthorization systems. There is also the
potential for education as the ordering physician may be provided with
feedback on why an imaging study is or is not appropriate and what
alternatives migh tbe provided. These systems are usually adaptable as
new evidence comes online, and are, hopefully, evidence-based. Clinical
decision support is the least obtrusive system, with highest acceptance
among providers .10,13 Overall, point-of-order clinical decision support clearly comes closest to the ideal system for imaging management.12 Less clear is the effectiveness of clinical decision support systems, which will be discussed below.
Scope of control of imaging
management may also vary in scope. A global approach addresses all
imaging studies and indications. From a practical standpoint, even if
this approach is limited to advanced imaging—CT and magnetic resonance
imaging (MRI), there are still literally tens of thousands of
indication/imaging procedure pairs. Unfortunately, the vast majority of
these imaging/indication pairs will be without strong evidence or even
consensus on whether imaging should be performed. However, several
vendors now produce and maintain the required vast libraries of clinical
decision support rules to drive the global approach. The hardware and
software platforms to support this approach can be purchased for any
size enterprise, though the cost and challenge of integration into the
existing IT infrastructure may be large.
An alternative approach
is to target imaging control to the limited set of imaging/indication
pairs where there is strong evidence that imaging should be performed.
Fortunately, the availability of evidence overlaps with a number of
common indications where imaging use is highly variable and likely
over-utilized. Particularly in young and commercially insured
populations, high utilization costs occur in high frequency, low
severity conditions. Thus, there is a potential for a high overall
impact through using a targeted approach to areas of high utilization
and strong evidence. Examples include lumbar MRI for low back pain,
brain MRI for headache, head CT for headache, sinus CT for sinusitis,
and selective applications of chest CT, including CT pulmonary
angiography. The targeted approach allows for organic development of a
system within the pre-existing IT infrastructure, potentially at little
Degree of imaging control
choice that must be made in a point-of-order system is the strength of
the barrier to inappropriate utilization. Clinical decision support can
be used in a purely educational manner, with information provided to
ordering clinicians regarding the appropriateness of a study, but no
barrier to ordering inappropriate examinations. The presumption is that
the educational effect of the critical decision support combined with
the ability of the managers of the system to track the ordering behavior
of providers (sentinel effect) would cause more appropriate imaging
use.Alternatively, a strong barrier or “hard stop” can be enforced,
where imaging requests that do not meet evidence-based criteria can be
blocked.The term for this approach at Virginia Mason is
“mistake-proofing,” since this method does not permit a mistake to occur
in ordering of advanced imaging. An intermediate stage would be to
require additional steps to order imaging when criteria are not met, but
still allow inappropriate ordersto proceed (“soft stop”).
How effective is imaging control?
of the clear advantages of point-of-order imaging control for all
parties, including radiologists, referring providers, patients,and
payers, we will focus discussion of effectiveness on this approach. The
largest published studies on the global approach come fromMassachusetts
General Hospital and from the Institute for Clinical Systems Improvement
(ICSI) work in the state of Minnesota. In both settings, a global
system was implemented for all advanced imaging, including CT and MRI.
The Massachusetts General Hospital group reported results on >300,000
CT exams and 200,000 MR exams for the years 2000-2007. The
investigators looked at imaging rates before and after implementation of
the clinical decision support. Following implementation of clinical
decision support,though the rate of advanced imaging continued to
increase, the rate of increase was slower. The annual growth rate of CT
scanning decreased from 12% to 1%. However the results for MRI were less
impressive — no different from the ultrasound control group where there
was no clinical decision support intervention. The MGH group also
reported that the proportion of studies considered to be highly
appropriate increased following the intervention.13
Minnesota, ICSI led a pilot program in advanced imaging clinical
decision support in 5 large provider groups. Following implementation,
the imaging growth rate dropped to virtually 0%.10 However,
the ICSI data are confusing, as imaging growth appeared to drop prior to
implementation of decision support. Also, there was concurrent
implementation of a preauthorization program at many sites that
confounds the results.
For both the MGH and ICSI programs,
computer decision support was used in an advisory and educational
capacity. The systems provided feedback to the clinicians, but requests
with low appropriateness scores were allowed to proceed to imaging. The
MGH group also reported some improvement in exam appropriateness when a
“soft stop” was implemented, requiring providers rather than support
staff to place orders with low appropriateness scores.14
targeted clinical decision support has been used at Virginia Mason
Medical Center in Seattle, WA, focusing the clinical decision support
system only on selected areas of high imaging volumes, strong evidence
or consensus around appropriateness, and potentially high
overutilization. The Virginia Mason system was developed organically
within the computer order entry system. A hard stop was employed whereby
requests for imaging that did not meet evidence-based criteria were not
permitted to proceed. The results of this program were more profound
than that observed in the MGH and Minnesota experiences. At Virginia
Mason, there was not simply a decrease in the rate of growth, but rather
a sustained 20% to 25% decrease in imaging rates in the target
conditions.15 The system was also low cost, not requiring the
purchase of a commercially available system, or the development of
thousands of individual decision rules. The decision rule set used
byVirginia Mason is freely available (https://www.virginiamason.org/body.cfm?id=5620).
addition, at the Everett Clinic in Washington State, the targeted
approach to clinical decision support was used in combination with
institutional process improvements to focus on decreasing inappropriate
imaging. At the Everett Clinic, imaging utilization for MRI lumbar
spine, CT sinus, and CT and MR brain for selected clinical conditions
dropped by 14% to 41% after the intervention (K. Weaver, MD,personal
communication). Though small, single institution reports, these results
do suggest that the targeted approach combined with a hardstop is
substantially more effective in eliminating imaging overuse than the
global commercial systems based on provider education.
What system to implement?
involvement of radiologists facilitates selection of more ideal
clinical decision support systems rather than the more traditional,and
intrusive preauthorization and billing denial. However, even within
clinical decision support systems, there are trade-offs between global
and targeted systems, as well as between purely educational systems or
systems that actually block inappropriate utilization. These choices
will vary depending on the individual practice and local medical
The choice between a global or limited approach to
imaging control depends on perception of the extent of the problem, and
the resources designated for the solution. There are potential
advantages to each approach. As discussed, the limited approach is much
more effective in reducing unnecessary imaging in targeted areas where
overutilization is prevalent and costly. If there is internal evidence
that excess imaging occurs inequivalent amounts across all clinical
conditions, then the global approach may be preferred. In addition,
health plan interests in managing all imaging studies may compete with
the targeted approach. However, the global approach also carries much
greater cost to providers, and challenges in integrating with existing
IT systems. Investigators in Manitoba found significant challenges in
implementing a commercial global system,including integration with
existing IT resources.16
Similarly, the choice between
educational systems and those that impose an actual barrier to
inappropriate imaging may be based on local factors. The educational
systems have high acceptance among providers13 and in some
locations may meet with less resistance than the imposition of actual
barriers. However, systems with strong barriers are the only ones
designed to prevent inappropriate imaging and which have also met with
high acceptance in selected settings.15 Limited data indicate
that methods with actual barriers are more effective. As an example,
theManitoba group reported that when using the CDS in a purely
educational capacity, without a barrier, <1% of studies graded as
inappropriate were averted .16
Table 2 delineates a series of questions that radiologists can use to guide their choice of imaging utilization approaches.
development of point-of-order clinical decision support now offers an
accepted and relatively easy-to-implement method for imaging management,
preferable to the more established and common pre-authorization
approach. Additional choices within clinical decision support systems,
between global versus targeted, and educational versus “mistake-proofed”
methods may depend on the organizational interests of providers.
However, the targeted, “mistake-proofed” point-of-service method is most
aligned with medical evidence, and likely provides the greatest
effectiveness in reducing inappropriate imaging for high-volume
conditions of high aggregate cost for purchasers.This method is clearly
less costly in terms of provider time per imaging study. Commercial
global systems cover a broader array of medical conditions than the
targeted approach and provide opportunities for provider education.
Further, global commercial systems without actual barriers to
inappropriate ordering may require less effort in securing acceptance of
providers. However, such systems are generally less effective, are more
costly to install and maintain, and are less amendable to modification
The consultative role of the radiologist in
determining when imaging is appropriate has always been a part of our
practice and training.However, increasing emphasis on appropriate
imaging mandates radiologist participation in developing methods of
systematic assessment and potential denial of imaging requests. This
active control of imaging to eliminate unnecessary testing is
challenging to radiologists as well as referring clinicians, but appears
inevitable in the context of increasing healthcare costs and
We greatly appreciate the collaboration
of Kelly Weaver, MD, of the Everett Clinic in Everett, WA, for sharing
imaging utilization data.
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- McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348:2635-2645.
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