1. Second Opinion: Is It Worth the Woe?

2. 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

3. The Breakdown Background Risks vs. Benefits Starting Out Potential Pitfalls Future and Follow-up

4. 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?

5. 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

6. 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

7. 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”

8. 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

9. 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?

10. 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

11. 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

12. 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

13. 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

14. 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?

15. 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

16. 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”

17. 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

18. 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)

19. 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)

20. 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?

21. 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

22. 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”

23. 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.