We live in a mobile culture. Most people change jobs, change locations, and change homes during their lifetime. When these events happen, chances are that healthcare providers are also changed. Because most medical information is situated at the site where an exam is performed, and obtaining that data can be problematic, anecdotal wisdom holds that many patients undergo duplicate procedures when switching healthcare providers.
A study undertaken at the Philadelphia Health Information Exchange sought to quantify the extent to which patients seek imaging care across a region's competing medical facilities. The study, presented at the 2006 RSNA conference in Chicago, suggests that sharing images across institutional borders could yield significant potential savings.
"The motivations for this work were trying to learn to what extent patients travel between competing imaging facilities within an urban metropolitan area," said Dr. Elliot Menschik, who presented the results of his group's research.
Menschik, chairman and CEO of Philadelphia-based healthcare services and information technology provider Hx Technologies, said that the team also sought to determine to what extent relevant priors are stranded in another enterprise that the radiologist is unaware of or unable to access; how often exams are duplicated in the process of patients moving to different facilities; and the potential impact of regional health information organizations (RHIOs) focusing on the exchange of radiology between enterprises.
The research team analyzed data from the Philadelphia Health Information Exchange, a regional network that electronically links unaffiliated healthcare facilities to share digital diagnostic imaging results among the different institutions. The exchange encompasses 450,000 unique patients at five hospitals and eight freestanding imaging centers in the region. It indexes patient demographic and imaging data (CPT-4 and ICD-9 codes) in near real-time through an interface with heterogeneous PACS and RIS at the facilities, according to Menschik.
The researchers analyzed the index to quantify the overlap between two major rivals in the Philadelphia market: Thomas Jefferson University Hospital (TJUH) and the University of Pennsylvania Health System (UPHS).
"The key problem is that patients have different medical record numbers across different facilities," Menschik noted.
They used a probabilistic linkage approach to match up the records as belonging to the same individual. A given patient was matched in a probabilistic fashion and a fuzzy comparison on an attribute-by-attribute basis was conducted against every other patient known in the region. A composite score indicating the likelihood of a match was then generated for every pair of patients, Menschik said.
The researchers then created custom structured query language (SQL) queries against the core database, and compared all studies for the same patient against one another. The data was also analyzed for relevant priors and duplicate exams by comparing CPT code pairs of exams.
The dataset encompassed imaging exams performed at TJUH and UPHS between January 2005 and October 23 this year. Researchers found that 6.2% of the Penn patients and 14.5% of the Jefferson patients were seeking care at the other institution, which meant that approximately 20,000 patients traveled between the two facilities and generated approximately 125,000 imaging exams during the 20-month period, Menschik said.
Relevant priors between the two facilities were 1,700 exams at the one-month mark in the study and reached more than 10,000 by its conclusion. Menschik noted that the time window for relevancy of priors varies on clinical condition and was not accounted for in the study. However, having access to relevant priors, particularly in cancer cases, is clinically significant.
"Diagnostic exchange between institutions is likely to have significant impact on quality of care," Menschik said.
On a modality basis, a CR exam replacing another CR exam accounted for 68% of the total, 7% for a CT for a prior CR, 5% for a CT for another CT, 3% for a CR for a prior CT, 2% for an MR from a prior CR, and ultrasound, nuclear cardiology, and other modalities making up the remainder of the priors. Trauma and respiratory conditions accounted for 36% of the total each, with the remaining 28% comprising circulatory, musculoskeletal, neoplastic, gastrointestinal, genitourinary, neurologic, and endocrine/metabolic clinical presentations.
The researchers also measured duplicative exams. Menschik observed that exams beyond a 45-day time window probably could not be reasonably considered duplicates. The group found 1,520 duplicates at this time horizon, with an estimated cost of $218,062, on the basis of 2006 Medicare Part B rates by CPT code.
"From a duplicative standpoint, this is really a cost to the risk holder," he said. "In a capitated market, that's going to be the imaging provider themselves; in other markets, it's going to be the payor, health plan, or managed care organization."
Menschik noted that the research did not measure avoidable exams, such as ordering a CT after viewing a radiograph when the existence of another, prior radiograph may not have led to such an order. In addition, the study only examined two enterprises within a metropolitan region; as more institutions are compared within that area, the data will change.
Finally, because the study took place in an urban area, the team does not yet know how well its findings can be generalized to suburban, exurban, or rural settings.
By Jonathan S. Batchelor
AuntMinnie.com staff writer
December 15, 2006
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