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www.totoku.eu Color Display Megapixel C M Y CM MY CY CMY K EuHos_Dec15.pdf 1 11.12.2015 10:53:42 A key to CDS implementation for better imaging utilisation The ESR iGuide Report: Cynthia E Keen Electronic radiology clinical decision support (CDS) systems, designed to help doctors order the most appro- priate imaging examinations for patients, offer a way to practice bet- ter medicine, to reduce the costs of radiology and help increase patient safety by preventing radiation expo- sure from inappropriate or unneces- sary exams. CDS technology has existed for years. Evidence-based guidelines from the American College of Radiology (ACR) and the ESR have been recommended for decades. Electronic medical record (EMR) sys- tems, with the capability for ordering diagnostic tests that CDS systems interface with, are in use in many hospitals. The challenges that exist are adoption, trust, utilisation and proof of improved results. Physicians and hospital admin- istrators recognise the importance and value of radiology CDS systems as imaging becomes more complex and increasingly relied upon for its diagnostic capabilities. Early adopters, such as Massachusetts General Hospital in Boston, which first started to use the technology in 2001, have docu- mented impressive, tangible benefits. But medical practice is a highly individual profession. The symptoms and conditions of patients are often unique and not uniform. Even though USA federal legislation mandates the use of CDS when ordering advanced imaging exams for Medicare patients before the end of this decade, adop- tion by American hospitals has been slow. Longstanding methods of patient management that do not include the use of appropriateness criteria, the need for customisation for a specific hospital’s needs, and the overall complexities of medicine have created barriers. Some are real, some imagined. All need to be over- come. For several years, the ESR has worked to establish a foundation for Europe-wide CDS implementa- tion. After announcing a partnership with the ACR and its commercial CDS partner, the National Decision Support Company (NDSC) at ECR 2014, the ESR began to work on developing appropriateness guide- lines for European harmonisation. First, the ESR conducted a full review of the ACR appropriateness criteria following a scientific method. It adapted these criteria to European practice standards and the latest evi- dence available. Content was divided into nine categories, largely corre- sponding to body areas. The ESR’s CDS Committee conducted rounds of content reviews with specialist members. ESR discussed the changes members recommended with the ACR Rapid Response Committee to determine where and how the European imaging referral guidelines should differ from, or be the same as, the North American guidelines. The prototype ESR iGuide was launched at ECR 2015, and includes more than 1,500 unique clini- cal scenarios, linked to more than 10,000 clinical end points. These cover approximately 80% of imaging requests for breast, cardiac, gastroin- testinal, musculoskeletal, neurologic, thoracic, urologic, vascular and wom- en’s imaging. Under the direction of Professor Luis Donoso, the Hospital Clinic de Barcelona has been the pilot site. Its 24+ months’ CDS use, in a limited capacity, is currently being analysed. News for 2016 is that the ESR hopes to launch six additional ESR iGuide pilot programmes in hos- pitals in various European countries. Marcel Wassink, director of NDSC Europe, explained that the ESR iGu- ide is designed specifically to meet the highly diverse requirements of the numerous European healthcare systems. The iGuide will be available in multiple languages. Its content is configurable to support individual country, region and hospital-specific practice guidelines and protocols. Users can add or modify criteria, which will be traceable to enable NDSC Europe to make local chang- es efficiently and provide automatic feedback to the ESR. These features will enable sites to adapt the guide- lines to their own environments, while capturing data from users to improve these guidelines. ‘At the most basic level, the objec- tive of the pilots is to start establish- ing ESR iGuide and the use of imag- ing referral guidelines in Europe,’ Wassink explained. ‘Since healthcare systems and practices in Europe are very heterogeneous, it’s important to have sites running in different countries to learn from a variety of experiences. The feedback from the pilots’ users will help to optimise the system and enable the ESR/ ACR review process to continually improve the guidelines.’ After six to nine months, he added, results will start to be analysed, with a focus primarily on changes and hopefully improvements in refer- ring behaviour, measured against the referrals before the CDS system was deployed. ‘Other instruments for analysis may be qualitative inter- views with users, speed of through- put, reduced waiting times for exams, better scheduling, cost savings, and reduction in overall dose exposure through the avoidance of inappropri- Dr. Martin Maurer is well placed to assess healthcare changes from the per- spectives of two countries. The German radiologist, who worked at the Charité University Hospital in Berlin for ­ several years, is now a Consultant at the Institute for Diagnostic, Interventional and Paedi­ atric Radiology, at Bern University Hospital (Switzerland). He also has a degree in business administration and holds a Master in Health Business Adminis­ tration. Along with clinical-radio­ logical research Maurer has carried out numerous health- economic studies in radiology. The best place for radiologists A German or Swiss paradise? The current political framework chang- es healthcare structures and compet- itive dynamics for medical services providers. These issues were raised at the 11th Management and Strategy Congress MARA (Management in Radiology) in Bonn, in autumn 2015. Dr. Martin Maurer, one of the congress organisers, explained: ‘The objective of the MARA Congress is not to hold pretty lectures but pri- marily to address the current weak points in the field of radiology.’ Are challenges to radiology man- agement comparable in these countries? Maurer: ‘Generally, the challenges and management objectives in radiol- ogy are not country-specific and are similar in Germany and Switzerland. Demands are increasing everywhere, due to the growing subspecialisa- tion, with very specific requirements and requests from referring doctors and the expectation of fast, high quality diagnoses – and this in the light of massively rising amounts of images. Radiologists also need additional time for activities such as participation in interdisciplinary tumour boards – and all this against a background of decreasing reim- bursements.’ Do financial aspects affect out- patient care? ‘Unfortunately, these are increas- ingly coming to the fore in both countries. However, the conditions for radiologists are still a lot better in Switzerland. Although medical services there are also calculated on a point scale and evaluated and reimbursed according to time spent on a service and the average time to establish a diagnosis, Swiss radiolo- gists in private practice still receive realistic compensation for services. This obviously leads to considerably higher reimbursements for all radi- ologists. In contrast, cost structures – for staff, cost of living and property are much higher. ‘Swiss patients receive invoices for all services provided. This cre- ates transparency and an awareness of the value of individual medical services. German patients covered by statutory medical insurance do not have this awareness, which pro- motes an overuse of services. ‘Looking at conditions for radi- ologists in Germany you have to ask how the system is supposed to work in the long term. From the service provider’s perspective, reim- bursement for treatment of a statu- tory health insured patient in many cases only just covers the costs. It may sound painful, but providing standard services for statutory health insured patients generates hardly any money for radiologists. From a health-political perspective the inten- tion appears to be for the private medical insured to subsidise treat- ment for those with statutory insur- ance, significantly to keep the infra- structure of out-patient care going. “‘Two-class” medicine is often quoted in this context. However, all German patients, regardless of their insurance cover, receive almost iden- tical medical treatment, apart from some better comfort in hospital and quicker appointments. Therefore, it’s a rather a “two-class” system from the service providers’ perspec- tive because identical services are reimbursed in different ways and radiologists in private practices are expected to simply accept this. ‘Germany’s problems result from too many statutory health insured patients making too small contri- butions in relation to their costs. This isn’t necessarily their fault: The overall level of income among the general public is too low for patients to make an appropriate contribution. In Switzerland the mean income is considerably higher and even an insured patient with a low income can still make a contribution that adequately covers costs.In Germany, I miss health politicians who make the general public honestly aware of these problems and finally will tackle structural problems that have been discussed for years. What is the hospital situation? ‘Swiss hospitals have also introduced DRGs, but are still unaccustomed to them and they worry about their high own costs. As a German I’m more relaxed about it, especially as the Swiss DRG base rates are about three times those of Germany. However, there is still a tendency to increasingly consider radiology as a cost factor that should ideally be kept low, meaning that the significant benefit of radiology departments for hospitals is being ignored. German hospitals don’t appear to value this, especially looking at the reimburse- ment proportion for radiological services compared to overall DRG reimbursements: “basic” radiological services, such as a chest or abdomi- nal CT scan, now receive extremely low reimbursements – a worrying situation where large parts of stand- ard radiological examinations merely contribute towards breaking even. ‘Swiss hospitals primarily must deal with high costs, which has resulted in a “clear-out” process for smaller hospitals that cannot be run profit- ably. On the other hand, the Swiss public is emphatic about the provi- sion of hospitals in remote locations, making it very difficult to close unprofitable facilities, from a politi- cal perspective. ‘Although many smaller hospitals also have high-quality radiological equipment e.g. CT and MRI scanners, they often don’t have radiologists on site overnight and at weekends for cost reasons, preferring to use the teleradiology services provided by Bern University Hospital.’ Which country offers the brightest future for radiologists? ‘It’s becoming increasingly risky and unattractive for German radiolo- gists to invest their own capital in infrastructure of their own practice because the costs are particularly high. Incalculable political decisions, such as the often discussed abolition of private health insurance, would soon have existential implications for many private radiologists. Therefore, having their own practice is no long- er attractive to younger radiologists. Existing practices are also investing less and less and a many older col- leagues appear intent on just reach- ing retirement age. This promotes the development of larger networked practices to minimise risks and cut costs through economies of scale. ‘I worry about the emergence of large practice networks with exclu- sively profit-oriented investors who buy up practices on a large scale– with no obvious criticism from the National Association of Statutory Health Insurance Physicians. ‘The lack of qualified young staff is a problem in both countries, because a large number of radiologists will retire in coming years. One posi- tive situation is that many younger women – and men – see this profes- sion as easy to combine with family. ‘It’s no use moaning about radiol- ogy’s prospects which I consider nonetheless being excellent. The need for radiological services will grow, as will a need for subspeciali- sation which will need comprehen- sive education and further training, whilst the cohesion as a profes- sion must be maintained. We should focus on making patients and refer- ring doctors aware of the importance of radiological services and continue to fight for adequate reimbursement. EUROPEAN HOSPITAL  Vol 25 Issue 1/16 8 EH @ ECR EuHos_Dec15.pdf 111.12.201510:53:42

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