The Truven Health Blog

The latest healthcare topics from a trusted, proven, and unbiased source.

Emergency Department Physicians Ordering Unnecessary Imaging Tests

By Byron C. Scott/Thursday, April 16, 2015

As a residency trained, board certified emergency medicine physician who practiced for over 20 years, I was not surprised entirely by a recent Health Leaders’ article stating that ED physicians order unnecessary imaging tests, based on a research article published in Academic Emergency Medicine in April of 2015.    

There is no question that as a practicing physician in the emergency department, you try to make decisions based on sound evidence-based medicine.  The reality is that other factors are constantly influencing decisions, such as patient demands, other physicians involved in a case, liability issues, and just not wanting to miss something that could harm the patient.  On multiple occasions during my career as a medical director and practicing emergency department physician, I have seen patients with a history and physical exam that did not justify ordering an additional imaging test,  however, medicine is an art and often instinct plays into decisions.  If emergency department physicians ordered tests based exclusively on what evidence based medicine supports, many emergent diagnoses would be missed causing a poor outcome for the patient.  The assumption is that not ordering a test because the evidence does not support it will protect you in a malpractice lawsuit.  However, those who have practiced medicine for years know this is not always the case.  

The best approach for now is to continue to look at innovative ways to engage patients and physicians.  For physicians, this will include having real-time prompts and reminders tied into the electronic medical record ordering system, based on evidence based guidelines that are easy to use and access.  Today, patient education and engagement tools are mostly used outside an acute emergency department, but perhaps these tools with their easy-to-use clinical information, statistics, and images could also provide real-time education for the patient to help explain why certain imaging tests are not required.   Tort reform may be one way to influence excessive ordering of diagnostics test but I believe the clinical instinct and art of medicine, as well as evidence based guidelines and patient education, are important to achieving the best outcomes.

Byron C. Scott, MD, MBA, FACEP, FACPE
Medical Director, National Clinical Medical Leader


Population Health: Economics and Leadership 101

By Byron C. Scott/Monday, May 12, 2014
Byron Scott imageIn a recent article in Healthcare IT News, the author did an excellent job of summarizing several key components of a successful population health program, illustrated by a short case study about how finance leaders at Legacy Health in Portland, OR partnered with physicians to educate them on the financial impact of cost drivers. When discussing population health, I find it helpful to remember the Kindig and Stoddart definition of population health from 2003: “Health outcomes of a group of individuals, including the distribution of such outcomes within the group.” This really helps summarize any framework and takes into account the end result of health improvement – how to monitor variability and the associated cost.

In order to have streamlined reporting, you need data. This sounds easy, but is often complex when extracting information from various health information systems (HIS) within a hospital or physician group. Many health systems have different electronic health record systems and having the tools and software to provide interconnectivity is essential. The data extracted must also be reliable, not only for clinicians, but for any other end user in the system that has a role in managing population health. Within hospitals, having this data will be essential when trying to reduce cost and variability in one key aspect of population health –  supply chain cost. In the article, the author mentioned reducing the use of more expensive implants in the operating room, but this is the tip of the iceberg. The continued streamlining of pharmaceuticals and other medical devices will be paramount in reducing overall cost.

As a physician, I believe partnering with physicians is essential. Some may call it being aligned, but I think calling it partnering is more collegial. Reducing physician variability requires reliable data that physicians can trust. Physicians are scientists and are often competitive, and if you provide them with trusted data, they will make improvements. However, it doesn’t just happen unless you provide physician leaders to guide them, and this requires investing in order to get a return. In other words, hospitals, health systems, and physician groups must continue to invest in physician leadership education and training to provide financially-astute leaders in the era of the Affordable Care Act.

Byron C. Scott, MD, MBA, FACPE
Medical Director, National Clinical Medical Leader

Reducing Readmissions Must be Addressed Across the Care Continuum

By Byron C. Scott/Wednesday, April 9, 2014
Byron Scott imageA lot of attention has been given to hospital readmissions in recent years, and the establishment of a readmission outcome measure by the Centers for Medicare & Medicaid Services (CMS) in value based purchasing has incentivized hospitals to work diligently on the problem. The recent article in Kaiser Health News about Beth Israel Deaconess highlights the challenges and obstacles we must overcame to reduce readmissions. The reasons to address this issue go beyond the cost of it. One reason alone should be to improve the overall quality by preventing the re-exposure of a patient to the hospital environment where they can be subject to hospital-acquired infections and other safety concerns, such as falls.

For some of the top readmission diagnosis like Heart Failure and Pneumonia, the biggest obstacles to reducing readmissions have been not what goes on in the hospital, but what occurs when the patient is discharged. It really involves more about the psychosocial aspect of healthcare than the science of the disease and treating it. When the patient is discharged after a heart failure exacerbation, the medical component is typically stabilized. The failures often occur in the process, communication, and overall care coordination. 
  • Was the follow-up outpatient procedure scheduled before discharge?
  • Is a family member or caregiver aware of the follow-up appointment?
  • Can the family member or caregiver drive the patient to the follow-up appointment? 
  • Did the patient receive the proper diet instructions before discharge?
  • Do they have the resources at home to help comply with the dietary guidelines?
  • Can the patient afford the prescribed medications, and does the patient understand the instructions for taking their medications?
  • If the patient needs outpatient intravenous antibiotics, were home health services arranged? 
These are some of the questions that must be asked in order to reduce the risk of readmission.

Hospital systems and hospitals that have been successful in reducing readmissions have ensured a coordinated team of visiting nurses, social workers, pharmacist, and case workers all work together to coordinate the process, education, follow-up visits, and overall answers to questions that may come up to family and patients. The future of our healthcare system  will be tied to coordinating care using an overall population health analytics system that not only tracts information across inpatient and outpatient settings, but also enables all care providers to communicate more effectively, tying in real time surveillance, monitoring, and alerts. Therefore no matter where the patient is along the continuum (inpatient, outpatient, emergency department, or home) and whoever is interacting with the patient, information is constantly brought together and communicated to improve the health of the patient and reduce risk of readmission for high risk patients and chronic disease.

Byron C. Scott, MD, MBA, FACPE
Medical Director, National Clinical Medical Leader

Health Information Exchanges Provide Valuable Information to ED Physicians

By Byron C. Scott/Wednesday, March 19, 2014
Byron Scott imageIf you polled every physician, especially emergency medicine physicians, in the country, and asked if it would be valuable to have access to patient data from Health Information Exchanges to help prevent unnecessary admissions from the Emergency Department (ED); the answer would be 100% yes. I applaud the study by Joshua Vest PhD at the Weill Cornell Medical College to continue the national debate and increase the awareness about the importance of health information exchanges to reduce costs and unnecessary care in the country. The state of New York and others have been on the forefront to invest in the exchanges.

I realize that many are afraid to allow access to health records across a large spectrum because of HIPAA concerns, but I can tell you that as an emergency medicine physician, it’s safer for the patient. Emergency medicine physicians are the gate keepers and the ultimate patient advocate. If you become a patient in the emergency department, your physician will need to access records and diagnostic test results to avoid performing repeat tests and creating unnecessary readmissions. Many times a patient cannot remember what was done, where it was done, or even the results of the test performed. Yet, the patient is brought to a hospital in the middle of the night by ambulance to a hospital in town they have not been to. Yet, they had a vital piece of information during another stay that could mean the difference in whether additional test or admissions are performed. Even in the age of electronic medical records and advanced technology, it’s still challenging to try to get information from an unaffiliated hospital, clinic, or doctor’s office.

I actually worked a 12-hour shift in the Emergency Department just last week. I saw a patient who suffered an injury but went to an Urgent Care facility just a few hours prior to seeing me in the Emergency Department. The patient had an x-ray at the unaffiliated clinic, and therefore I didn’t have access to this information. It was a diagnostic test I needed to visualize to make the correct treatment and disposition decision. Fortunately, the urgent care clinic made a copy of the x-ray on disc and gave it to the patient. Thankfully, he brought it with him, preventing me from ordering another x-ray, adding to the cost of his treatment, and exposing him to additional radiation exposure. I was lucky in this scenario, but countless physicians (me included) could tell you stories where if we had access to information quickly, we could not only reduce cost, but improve customer service to the patient. 

We must continue to educate and support the need to Health Information Exchanges to improve safety, reduce cost, and improve efficiency. This further buoys the conversation about Population Health and the continued need for integration of clinical and administrative data on a real time basis.

Byron C. Scott, MD, MBA, FACEP, FACPE
Medical Director, National Clinical Medical Leader

Hospital-Physician Alignment Key to Hospital Success

By Byron C. Scott/Wednesday, February 26, 2014
Byron Scott imageFinally, physicians come to the forefront as the connecting link that will help hospitals address and improve financial targets in the next three years. Physician-hospital alignment tops the list in the latest HealthLeaders Media industry survey, "Forging Healthcare's New Financial Foundation," and it’s noted as the most important area of focus and improvement, followed by cost reduction and care model direction. These three areas are key as we navigate from volume-based care (or fee-for-service) to value-based care. Physicians have significant influence on quality and the process of care improvement, since they are the delivery agents. Many definitions of quality exist, but every physician and hospital is constantly evaluated on quality by organizations such as the Centers for Medicare & Medicaid Services (CMS), in addition to independent rankings such as the Truven Health 100 Top Hospitals® study.

First, it’s crucial to make sure there are enough physicians. Current Truven Health  data shows differences in productivity by age cohort, and findings show that a retiring physician may need to be replaced by more than one new physician to see the same number of patients. Second, it’s essential to have enough physicians in the right structure.

In the organized structure, there needs to be the right performance-based contract and compensation in place to ensure alignment. Part of this structure includes having the physician leadership at every level in the organization. This includes medical directors, department chiefs, and C-suite physician executive leadership. Third, make sure that physician leadership is selected, trained, and resourced to make the leadership decisions for value-based care. Knowing the practice variation amongst the group and the group variation versus benchmarks helps us understand the drivers of each group and practice to implement changes to better support the practice and reduce variation. The key to this is having health analytic tools to extract the data to measure and compare. As Walter Deming once said, “You can’t manage what you can’t measure.”

Byron C. Scott, MD, MBA, FACPE
Medical Director, National Clinical Medical Leader