1 measuring and improving quality in medical imaging john mathieson md bob clark viha
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1
Measuring and Improving
Quality in Medical Imaging
John Mathieson MDBob Clark
VIHA
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Measuring and Improving Quality
in Medical Imaging
Current Areas of Interest in VIHA
and
Overall Perspective
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Measuring and Improving Quality in Medical Imaging
• Huge potential gains• Many current problems• Hard to Measure, Hard to Improve• Expensive
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Current areas of interest
1. Typical Report Accuracy analysis
– CT Virtual Colonoscopy Project
2. Novel Electronic Systems
3. Report Turn-around Time - Productivity
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Current areas of interest
• Report accuracy – how to measure?• Manual method
–Expensive–Time consuming –Not done routinely
• Current project – CT Virtual Colonoscopy – Endoscopic Pathologic correlation
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Measuring Work Quality
Polyps called at CT VC – – What is found at Colonoscopy / Pathology?
Hire someone to track down clinical follow-up and correlate
Traditional statistics – PPV NPV etc
Not ordinary part of workSpecial Project
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Current areas of interest
• Both the Imaging reports and the final diagnoses end up computerized –
–BUT – no method of automatic linking and feedback
• Ideally – all reports cases with some kind of proof would feed back to original reports
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Other Questions – How many cases do new readers need to
be qualified to read CT VC?
• Wild guess• Nice sounding round number
• Actual Data– Measure accuracy vs experience– Subjective self assessment
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CT VC Reader Assessment
• Testing on unknown cases at various points in experience
• Subjective – ask all readers to describe their own experience with retrospective recommendations
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Potential for Electronic Systems
• Commissure – voice recognition for Intelligent text analysis
• Categorize reports automatically – positive / negative, other
• Correlate with – Indications / History
- Referring MD
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Industry Overview
• Radiology is wrestling with optimizing the appropriate use of imaging, spiraling costs, decreasing reimbursements, and its role in improving patient outcomes.
– Over 1 billion radiology exams performed each year in US
– Fastest growing component of medical costs
– Compound annual growth rate (CAGR) of 20%
– Over $100 billion in annual US diagnostic imaging costs
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Overview: Technology Background
• Appropriateness database consisting of over 11,000 rules based on patient demographics and covering MRI, MRA, Breast MR, CT, CTA, PET/CT and Cardiac Stress Testing
– Foundation based on ACR Appropriateness Criteria® – expanded to cover broader range of imaging procedures – with input from over 1500 clinicians at MGH/Harvard
– Exclusive license agreement for rules database
– Utility score (1-9) appropriateness ratings
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Overview: Decision Support Utility Score
• The appropriateness scores range from 1-9 and are associated with the following relevance:
Indicated (7-9): indicates the desired exam is appropriate given the indications
Marginal (4-6): while the desired exam may yield results, a more appropriate exam may exist
Low (1-3): indicates the exam is less than optimal and more appropriate imaging techniques should be considered
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Real World Case: Massachusetts General Hospital
• Low-utility (inappropriate) exams decreased significantly, from 11% of the total CT volume before implementation to 4% by the end of the study period.
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Real World Case: Massachusetts General Hospital
• The portion of high-utility (appropriate) CT exams rose significantly, from 86% before implementation to 93% after referrers learned to use the system. The trend was the same for MR.
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Real World Case: Massachusetts General Hospital
• Overall CT and MR utilization was also affected. CT use rose at an average 4% in each quarter from 2001 to 2003. The curve flattened after implementation, reflecting slowed growth. Again, a similar trend was seen for MR volume.
• Positive findings in radiology reports increased from 74% to 84% for CT and 73% to 85% for MR.
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Total Outpatient High Cost Imaging Volume Trends
Radiology DS Implementation
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MR Spine Positivity by Specialty
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Fully integrated from Order Entry to Results Analysis –Results – feed back on ordering criteria
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Possibilites for Data Analysis / Quality Measurement
• Front end • Back End• Linking Front End with Back End
• Ordering physician audit• Audit by Indication• Audit by radiologist
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Turn Around Time – Productivity
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Turn Around Time – Productivity
• Many steps involved – one of which is - Once study completed
– how fast to dictation and sign off?• Extremely variable
Under 24 hours to Over 1 week
• Problems with slow turn around• Delayed treatment decisions• Longer hospital stays• Extra work created – phone reports etc
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3 Kinds of Workers
Turtles
Racehorses
Everyone Else
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Turtles
Slow, steady, very attentive to detail, unhappy with change and pressure, miss very little
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Racehorsesaka
Vacuums
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Everybody Else
Sometimes fast, sometimes slowDistractible, curious, intelligent
Easily bored - “Focus-able”
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What can you modify ?
Speed of reportingQuality of reportingTime spent reporting vs other thingsWork hoursDistribution of work
Easy thingsHard things
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Everyone
Good, conscientious peopleProud of their workAt least some degree of :
people pleasing need egoinsecuritycompetitiveness
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Versions of the TRUTH
People WILL shirk work they don’t like
People WILL get away with things
What you don’t count and measure will hurt you
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Your co workers are extremely good people
You are lucky to work with them
Collegial competitiveness is better than cut-throat aggression
Versions of the TRUTH
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Observer Effect
• It is impossible to accurately measure anything, because the act of measuring affects the answer
• Thermometer to measure absolute zero- the thermometer warms up the room
BAD THING – or GOOD THING ?
Why not try to MAXIMIXE the observer effect to get the Maximum change in the answer?
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Count and
Measure
Study Report Status - Statistics GeneratorReport from 01/12/2007 to 01/13/2007+=+=+=+=+=+=+=+=+=+=+=+=+=
+=+=+=Date: Sat Jan 13 03:45:03 2007
Total Results Dictated: 1001Total Results Transcribed: 959
Radiologist Results Dictated ----------- ---------------- rjsmith 46 dshea 15 vvanraalte 56 nfinn 110 forkheim 126 dzacks 114 brlee 55 jmathies 123 dconnell 91 cvwinc 11 dchu 61 jwrinch 67 iweir 42 goodacre 24 whodgins 60
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Problems
Racehorses vacuumed up everything
Others began to relax
Racehorses started to get annoyed
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Basic Minimum - Quota
Consensus on a reasonable amount of work for each rotation
Background vs Variable Work
Example – US and GeneralDo all the US at that locationPlus – X number of
Radiographs
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Quota Counter
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Plus / minus scores – like hockey
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Results
• Dramatic reduction in turnaround time– Actual measurement VGH – 67%
• Dramatic shift in time of day work is done
• Feelings of fairness, equity and group harmony
Unexpected ResultSpeed with which expectations changed
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Quality in Medical Imaging
Areas of Concern• Access for Patients• Access to
Information• Image Quality• Patient Safety• Report Accuracy• Report Delivery
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Access for Patients• Lack of access – wrong dx, unnecessary
surgery, wrong surgery, untreated conditions• Wrong test – right test hard to get – do inferior
test• Economic models – Activity based funding vs
Block Funding• Spend budget wisely – justify expenditures
– $100,000 is equivalent to 12,500 extra CT scans !
• A BIG Problem
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Access to Information
• Integrated PACS / RIS / HIS systems• Integrated into community offices• “Middleware” – functionality
Host of benefits – accurate timely info- appropriate tests, no uneccessary repeats, right test first time, timely delivery important results
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Access to InformationProblems
• Slow implementation of systems
• Expen$ive
• Privacy / Security Concerns– Often the balance between Access and Security is Skewed by Paranoia over security Access Security
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Image Quality
• Equipment replacement – inventory maintenance – no financial model
• Single year purchases with wildly fluctuating amounts – Chronic inability to replace worn out
equipment– “Normal” to have some equipment
running that is not safe or diagnostic
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Traditional DAP role –
Radiation dose vs Image Quality
• Sad truth – long history of operating poor quality equipment due to lack of funding
• What should be done? Put some teeth into DAP
– close down unsafe equipment
» change funding model
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Summary• Many areas to focus on – beyond
traditional scope
• Clever use of electronic systems can make quality improvement more practical and routine
Access for PatientsAccess to InformationImage QualityPatient SafetyReport AccuracyReport Delivery
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