Sanford has a standardization committee that creates protocols for routine examinations. It's composed of an ED physician, senior physician leader, and people from the radiology department, explains Wynia. "We come to an agreement on what is best for the safety of patients and what we can get reimbursed for." Technologists also review every test to determine if it is the right test or if there need to be additional tests performed to get the answer the physician is seeking.
Massachusetts General Hospital opted to automate its decision support. The hospital developed a radiology order entry system that is connected to its electronic medical record and provides decision-support capabilities. The ROE system was implemented seven years ago and the decision-support component was added in November 2004.
The physician enters the patient's symptoms and diagnosis, and then the system factors in the patient's age and gender and provides guidance on whether the exam being requested is appropriate, explains Jeffrey Barth Weilburg, MD, the associate medical director for the Massachusetts General Physician Organization, which represents the approximately 1,600 employed physicians at MGH.
The system also provides duplicate exam alerts so doctors can evaluate prior exams of similar type to see if those reports provide necessary clinical information. "Decision support is a guide for physicians to understand [if the requested exam] is likely to be appropriate or not," says Weilburg.
Since decision support was added, the growth rate of CT scans has declined, says Weilburg; he credits ROE as one of the reasons MGH has done well meeting its pay-for-performance imaging utilization targets.
"Many people feel the healthcare delivery system has had difficulty monitoring itself and blame the rise of healthcare costs—at least the utilization component of healthcare costs—on the incentives that impact the providers," says Weilburg. Basically, they feel that physicians get paid for running tests and ordering labs, not keeping the patient healthy. "That is a gross oversimplification of an extraordinarily complicated problem, but there is some truth to it," he says, adding that unfortunately, it has led to the payment side of the healthcare equation imposing external regulations, such as radiology benefits managers.
One of the key differences between MGH's ROE system and a PBM is the decision to order a test remains in the hands of doctors. They may have to answer additional questions but, ultimately, it's their choice.
"The most important thing is letting physicians guide medical management because they have to deal directly with patients," Weilburg says. An external system can say they won't pay for it, but they bear no responsibility in that decision, he says. "The physician does, and the patient bears ultimate responsibility for what happens."