Second Opinion: Is It Worth the Woe?

A Special Thank You to: Dr. David M. Yousem, M.D., M.B.A. Professor, Department of Radiology Vice Chairman of Program Development Director of Neuroradiology Johns Hopkins Hospital for allowing the use of his material/content in this presentation Dr. Yousem’s online lecture series can be viewed at: http://webcast.jhu.edu/mediasite/Catalog/pages/catalog.aspx?catalogId=7e18 b7d5-9c63-487e-aaf1-77a86f83b011 Dr. Yousem’s project was funded through an RSNA Educational Grant

The Breakdown

• • • • • Background Risks vs. Benefits Starting Out Potential Pitfalls Future and Follow-up

Background

• • As medical imaging becomes more readily accessible by innovations such as PACS and teleradiology, there is often the expectation of the second-opinion consultation by patients and referring physicians – Increasing sub-specialization of radiologists may also add to this as a general community radiologist may not have the same resources as a trained sub-specialist This has several implications for radiologists and their patients – Though shown to improve patient safety, it has also been show to affect radiologist productivity – What are the costs vs. benefits?

Risks vs. Benefits

• Concerns: – Medicolegal implications – Lack of reimbursement associated with coding issues – Productivity effect – Technique used by outside institutions • Benefits: – Patient safety and satisfaction – Collegial contacts – Potential for reimbursement – Already in widespread practice

Concerns: Medicolegal Issues

• Ethical and Legal Responsibilities – If something was previously missed, what is the correct and ethical way to report it?

– Retrospective lawsuits?

• Precedent of litigation based on a second opinion exists in other specialties » Films are available for several years at the minimum » Easy transfer of information

Concerns: Lack of Reimbursement / Coding Issues

• Very strict requirements for reimbursement 2 – Written report – Documentation of medical necessity • Even stricter given that payer has already paid once for this service – Balanced billing requires patient to fill out beneficiary notice form in advance • Coding dilemmas – CPT code 76140 (second opinion consultation) • Originally designed for X-rays only – Now, “26” modifier after CPT code for original study (“77” for Medicare) • “Professional fee only”

Concerns: Productivity Effects

• • • One large study at a tertiary care center demonstrated an 18% increase in the daily workload 3 – 78% of the exams were cross-sectional – Mean of 18 studies were reinterpreted per day – Approximately 20% of the workday was spent reviewing these exams Majority of this work is not compensated Unmeasured impact – Delay in interpreting primary studies – Disturbance of daily workflow (dictations, consultations, etc) – Educational value to residents/fellows

Superiority-of-Search

• Several previous studies examine the way that radiologists review images 1 – Search (film reviewed de novo and significance evaluated) vs Nonsearch (findings previously identified and significance evaluated) – Search protocols found to be superior • Nonsearch protocols with higher false positive rates in large review of CXRs – Second-opinion consultations often fall under “nonsearch” • Have previous report available • Does this affect the associated legal risk?

Concerns: Technique Differences

• • • Often unsure of exact technique used – How much contrast?

– How much radiation?

• Is the second opinion consultant also responsible for radiation safety issues though exam was not at the primary site?

Too many or too few - which is worse?

– MR sequences / CT reformations Lack of prior exams which may have been available to primary interpreting physician

Benefits: Patient Safety

• John’s Hopkins neuroradiology department demonstrated significant discrepancies between original and second-opinion interpretations 4 – 7.6% of studies had differences which affected patient care, diagnosis, and/or management (1/13 cases) – Control internal error rate was 1.4% – For neuroradiology, seemed most often to be head & neck cases – Often had overcalled congenital variants • Rare entities seen less often in private practice vs. academic

Benefits: Collegial Contact

• • Become the “face of radiology” – Allows face to face or phone contact with several referring physicians – Value-added service Radiologists as clinicians?

– Interdepartmental discussion allows the medical community to view radiologists as clinicians not technicians – Radiologists are often perceived as “obstructionist” • Allows radiologist to help facilitate accurate and timely patient care • Increased physician dependence on imaging interpretation

Benefits: Potential for Reimbursement / Service Already Exists

• • • Any time a written report is correctly generated there is always the potential for reimbursement Service already exists whether or not departments have an official policy Avoids “curb-side” consultation which may be more costly in terms of time and medical-legal risk – disrupts workflow more than studies which are already DICOM integrated – verbal consultations may be misquoted in official hospital records/physician progress notes 2

Starting Out

• Departmental/Section physician consensus • All participants must be on the same page regarding risk/benefit valuation • Explain/Offer service to referring clinicians • Must see as a value-added service • studies will be in PACS system, no self-interpretation, no need to interrupt workflow to find a radiologist • Billing/Coding help • Previously described strict criteria and low potential for reimbursement • IT support to integrate outside images into PACS • What about images that are not DICOM compatible?

Implementation Tips:

• • • Try small pilot program in a single section of the department – Introduces added workload gradually – Evaluate feedback from department and referring clinicians Need patient service representatives comfortable with technology – CDs need to be transferred, images need to be digitized – Professional attitudes during interaction with patients and referring doctors daily – Should be able to provide digitization/upload service 24/7 as goal to avoid time delays in interpretation (especially if 24/7 film reading is available) Billing Coordinator – Need billers and coders familiar with services provided and reimbursement rates

Additional Issues:

• • • • Non-DICOM policy – For example, “we will not interpret images which are not provided in a PACS compatible format” vs. “outside CDs can be submitted even if they are unable to be uploaded to PACS” Referring physician request slip – Customized – Typically include reason for reinterpretation, is outside report available (yes/no), is delivered CD to be destroyed or returned?

Patient signature must be acquired before interpretation on beneficiary notice form General policies must be created – For example, “we will not interpret studies older than 30 days old”

Additional Possibilities:

• • Departmental Rounds – Department of radiology employee makes rounds to clinics collecting patient provided imaging to be uploaded and interpreted Provide service to private patients not being seen at a physician’s office – Patient driven second-opinion search

Acquiring Physician Feedback

• • • • Conducting surveys of referring physicians – Program is only successful if referring clinicians are satisfied and recognize value added Are reports satisfactory and/or helpful?

Observe disc submission to report turn-around time – Has it changed the need for additional pre-operative imaging as outside images may now be on PACS?

Constantly adapt and mold the program to meet the needs to referring clinicians and patients – Feedback must be acquired at regular intervals (more frequently during implementation process)

But Is It Really The Best for Us?

• • • Lack of direct patient contact – The patient is often not even on-site to make this possible Limited patient history – Interpretation of an image without the pertinent clinical history can do more damage than good • Examples include neoplastic diseases that mimic inflammatory processes or vice versa Interpretation limited by quality of study – May not always have copies of all images that were obtained (patient disc may only have “pertinent images” - Example, reformats included but source data not present)

But Is It Really the Best for Us (cont)?

• • Radiology practice may become more driven by medicolegal factors – Interpretations based on knowledge that images may be reinterpreted differently – Potential for legal precedent to be set regarding malpractice from reinterpretation of studies Payment collection issues – Know which insurers will pay – What about patients who are expected to self-pay?

Potential Pitfalls

• • • Disrupts the general workflow / Overextends staff – An increase of 18% per day may not be feasible Large amount of uncompensated time – Especially pertinent in private practice or productivity based/RVU type payment schemes May require hiring of additional personnel – Billers, coders, customer service representatives

Future and Follow-Up

• • Promise of continued growth in the demand for second-opinion consultations as radiologist workflows become more streamlined and PACS makes images readily available to both clinicians and patients – There also may be the potential for reimbursement in this arena which is currently lacking Incorporation of an efficient and effective second-opinion consultation service may improve patient safety and care as well as the perception of the radiology community by referring physicians – The future of radiology is secured by making radiologists “value-adders”

References

• • • • 1. Swesson, R. “Search and Nonsearch Protocols for Radiographic Consultation.” Radiology. 1990: 177, 851-56.

2. Duszak, R. “Another Unpaid Second Opinion”. Journal of the American College of Radiology. 2005. 2(9), 793-4 3. DiPiro, P., et al. “Volume and Impact of Second-Opinion Consultations by Radiologists at a Tertiary Care Cancer Center.” Academic Radiology. 2002; 9: 1430-33.

4. Zan, E., Yousem, DM, et al. “Second-opinion Consultations in Neuroradiology.” Radiology. 2010; 255(1): 135-41.