Nuance - Healthcare Solutions

Controlling Costs and Unnecessary Ordering

With over 1 billion radiology exams performed each year in North America; diagnostic imaging is now the fastest growing component of medical costs. Aside from the immediate need to control the over $100 billion in annual expenditures on high-tech diagnostic imaging costs, the medical community should also focus on minimizing the impact of unnecessary radiation exposure. A significant percentage of diagnostic imaging spending may be unwarranted due to:

• Physicians worrying about malpractice lawsuits
• Physicians being unaware of the most diagnostically appropriate use of rapidly-developing technologies
• Physicians facing increasing patient demands for testing
• Self-referrals to office-owned imaging equipment

An Alternative to RBMs

The use of CT, MRI, PET and nuclear cardiology imaging procedures has steadily increased, fueling an unsustainable upward trend in healthcare costs and potentially exposing patients to unnecessary radiation. Health plans have launched pre-certification processes to help ensure appropriateness of these high-technology diagnostic imaging (HTDI) scans, which has added expense and clinic inefficiencies to the provider ordering process.

RadPort offers an alternative to radiology benefits management (RBM) companies and satisfies healthcare payer pre-certification requirements. What’s more, RadPort assists with billing by accurately capturing structured ICD-9 indications. This alleviates wait times, speeds patient diagnosis and offers significant cost savings while improving patient outcomes and satisfaction.

DS Rules Engine and Utility Score

RadPort is powered by over 15,000 peer-reviewed clinical criteria that are continually evaluated and revised by a clinical committee. The clinical guidelines are based on ACR Appropriateness Criteria® and have been expanded and licensed through an exclusive agreement with Massachusetts General Hospital. The rules engine includes decision support (DS) for high-tech diagnostic imaging such as MRI, MRA, Breast MR, CT, CTA, PET/CT and Cardiac Image Stress Testing.

An evidence-based utility score system evaluates the appropriateness of each exam as it’s ordered, eliminating the need for physicians to spend excessive amounts of time with utilization reviewers. This penalty-free approach to ordering and an easy-to-use scoring methodology ensures consistency in ordering practice patterns.

Benefits: Payer, Provider, Patient

The benefits of decision support are far reaching. Payers benefit from the cost-effective management of appropriate high-tech imaging utilization with an affordable PMPM. Providers benefit from improved ordering patterns and pre-certification without the need for costly RBMs. Patients reap the added security that the appropriate order is placed the first time around – thus lessening unnecessary exposure to excessive radiation, reducing additional healthcare bills and limiting the loss of work and family time.

Improving Patient Outcomes and Monitoring Results

Decision support is only part of the equation. While RadPort guides high-tech imaging ordering and offers safety precautions like duplicate exam warnings, back-end data analysis is required to complete the utilization management chain. With RadCube, the outcomes analysis and utilization management software that complements RadPort, administrators can monitor the utilization of modalities at any given site or location and track ordering patterns of physicians and practice groups to provide continuous feedback on appropriateness ratings and ordering mix. Your organization can analyze the use of decision support, using variables such as:

• Structured (ICD-9) indications
• Ordering clinician and practice groups
• Insurance company data
• Order exam and exam group
• Number of change iterations
• Decision support group (red, yellow, green)
• Decision support score (1-9)
• Decision support number (DSN)

For each patient encounter, diagnostic imaging report data is merged with RadPort decision support data allowing you to evaluate the entire episode of care. Understand your facilities ordering and reporting data better and make more informed business decisions through the combined use of RadPort and RadCube.

Radiology Solutions Leadership

RadPort represents the next step in the expansion of the Nuance family of radiology solutions. The addition of RadPort™ to the market-leading PowerScribe®, RadWhere™, Veriphy™ and RadCube™ solutions provide end-to-end intelligent ordering, speech-driven clinical documentation and automated delivery of critical test results, while offering a powerful set of tools for retrospective analysis of utilization review and appropriate ordering patterns.

Based on ACR Appropriateness Criteria
Derived from the American College of Radiology (ACR) Appropriateness Criteria®, and designed in conjunction with Massachusetts General Hospital, RadPort’s scoring methodology is continuously reviewed and updated by a panel of clinical and radiology experts.

Proven “utility scores” guide ordering
RadPort combines the clinical information provided by the referring physician at the time of ordering with patient demographics to produce a “utility score” for the examination requested.

A high score indicates that the information provided strongly supports the use of the requested imaging test. A low score indicates that the request may not be appropriate. As a result, RadPort displays alternate procedure choices with corresponding utility scores of other relevant and appropriate exams.

In the event of a low score, RadPort provides clinical reference material designed to educate the referring physician so as to ensure appropriate ordering in the future.

Satisfies pre-certification requirements
RadPort satisfies healthcare payer pre-certification requirements, circumventing the need to use traditional Radiology Benefits Management (RBM) companies. Instant pre-certification eliminates wait times and offers significant cost savings while improving patient satisfaction. Furthermore, by accurately capturing indications you can ensure proper billing.

Manages unnecessary (low utility) ordering
A low utility decision support score does not necessarily prevent a referring physician from ordering an examination. However, if a physician decides to proceed and order the procedure, s/he is required to enter a reason for her/his decision. RadPort collects this data to assist with future decision support rule edits and modifications.

Furthermore, utility scores for each individual clinician and each examination type are collected over time. Utilizing the RadPort and RadCube™ applications, a facility can routinely analyze this data to provide feedback to the referring base on the appropriateness of their order mix.

RadPort is the perfect complement to an existing Computerized Physician Order Entry (CPOE) system. The decision support rules are implemented directly into the existing order process to ensure clinical appropriateness.

Analyze utilization, monitor ordering patterns
Proactively, the application will warn the ordering physician of duplicate orders for the patient. Retroactively, administrators can monitor the utilization of modalities at any given site or location and track the ordering patterns of physicians.

Take full control of ordering analysis through the use of RadCube for Radiology. You can examine ordering appropriateness by group, subspecialty or individual physician. Or, you can conduct facility-wide decision support scoring analysis as well as modality/procedure-specific trending. You can understand your data better and make more informed business decisions through the combined use of RadPort and RadCube for Radiology.

Using RadPort to automate RBM functions, significant cost and time savings can be realized.  Providers can log in and order high-tech imaging cases in seconds; the system presents a concise list of signs, symptoms, known diagnoses, abnormal priors and evaluates a specific case for medical appropriateness; RadPort then recommends a higher utility exam, should one exist; and physicians can then change the order to select the most diagnostically appropriate procedure, thus, providing accuracy, convenience and an electronic record that the appropriate action was taken.

1. Patient visits referring physician and describes symptoms/indications.
2. The referring physician logs into the web-based RadPort application (or uses RadPort integrated with their CPOE).
3. After entering the patients signs, symptoms, known diagnoses and any abnormal priors; the physician is presented with a utility score indicating the “appropriateness” of the desired exam choice and any alternate procedures to consider.
4. An exam choice is made and a Decision Support Number (DSN) is generated.
5. The procedure is placed and exam scheduled.

Q:	How was the RadPort™ Decision Support rule set created? Do they get routine updates?
A:	RadPort™ rules are based upon the ACR Appropriateness Criteria and then enhanced through input from numerous clinicians and specialists. The current system includes almost 15,000 relational rule-pairs that cover over 65+ high-tech diagnostic imaging studies. The feedback process is continual and the decision support rules are update on a regular basis.
Q:	How is RadPort™ deployed?
A:	RadPort™ is a completely web-based application that only requires a secure login to access the system. This web-based architecture allows for remote management and updates. RadPort also may be integrated into existing CPOE applications.
Q:	Can we use RadPort™ Decision Support rules if we already have a CPOE?
A:	Absolutely. In fact, many institutions are venturing this avenue so as to integrate decision support rules into their existing ordering process. Please contact our sales team to discuss existing partner organizations and our integrated efforts to provide appropriateness guidance.
Q:	Do we have access to metric data?
A:	Yes. We collect data to monitor ordering patterns, decision support scores, change iterations, indications, utilization management and more. This data may be analyzed through integration with Nuance RadCube™.
Q:	Who uses this system within the institutions and organizations?
A:	There are 2 popular models: Model #1 – referring clinician offices call a central scheduling office where the schedulers are logged into the RadPort system and ask the caller for the patient details. Model #2 – the clinicians (or designee) log into the web hosted or CPOE-integrated application from their office and enter the information themselves.
Q:	Do providers really enter their own orders?
A:	At the sites where this model type (model #2) is deployed, approx. 60% of clinicians enter their own orders, while 40% are entered by the designees.
Q:	Is RadPort for outpatient use only, or can we use it for inpatient studies?
A:	Currently, RadPort is widely used for ordering outpatient studies; however, there are organizations utilizing the RadPort decision support rules in the inpatient setting.
Q:	Can we use RadPort for our scheduling service?
A:	No. RadPort, depending on the extent of integration, can only be used to generate an “order request” and does not actually place or schedule an order.
Q:	What is the DSN number?
A:	The Decision Support Number (DSN) is a unique, identifier (#) that acts as a digital receipt to prove that the decision support process was completed for an individual patient transaction. The DSN is then tagged to the RadPort transaction and follows the order throughout the process allowing for other systems to query for further information (such as RadCube). The DSN also can be delivered to payers to satisfy pre-certification requirements.

Research

• Effect of Computerized Order Entry with Integrated Decision Support on the Growth of Outpatient Procedure Volumes: Seven-year Time Series Analysis
• Quantifying the Effect of Computerized Order Entry with Decision Support (RadPort) on the Growth of CT Imaging Volumes

Product Sheets

• RadPort

Whitepapers

• Closed-Loop Radiology Managing the Order-to-Results Delivery Cycle for Improved Diagnostic Imaging Utilization, Documentation and Patient Care
• Strategies for Closed-Loop Radiology Workflow

An alliance of leading healthcare providers, technology companies and diagnostic imaging organizations have joined forces to form the Imaging e-Ordering Coalition (The Coalition).  This national initiative will promote Health Information Technology (HIT) enabled decision-support (e-Ordering) as a solution to assure that all patients receive the most medically appropriate diagnostic imaging test for their specific condition. Members of the Coalition are devoting their energies to help educate policy makers and healthcare providers about the patient-centered efficiencies of e-Ordering, as well as recommending to lawmakers that the efforts to build incentives for prescribing medications electronically (e-Prescribing) should be broadened to include diagnostic imaging e-Ordering solutions.  

There are a variety of active legislative and regulatory proposals that attempt to address the utilization of imaging services for publicly subsidized programs such as Medicare and Medicaid.  The Coalition is focused on the following components and has achieved measured progress within each:

• Promote existing HIT legislative concepts to inform policy makers on the value of e-Ordering to enable the appropriate use of imaging.
• Ask lawmakers to include e-Ordering in the development of healthcare system efficiency incentives.
• Act as a resource for the Centers for Medicare and Medicaid Services (CMS) on its Medicare Imaging Demonstration Project established by Congress in Section 135(b) of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA).
• Work with policy makers to have the Coalition’s e-Ordering proposal for CMS scored to validate long-term value and savings for the healthcare industry.
• Work with stakeholders to establish standards to accelerate e-Ordering as a meaningful and valuable application with EHRs.

The Imaging e-Ordering Coalition is represented by legal authority and lobbying firm, Holland & Knight. For information on membership please call +1 (202) 457-7004. To date, the following organizations are members of the Imaging e-Ordering Coalition: Nuance Communications, Inc., American College of Radiology (ACR), Center for Diagnostic Imaging (CDI), GE Healthcare, Medicalis, and Merge Healthcare.