Second Opinion: Is It Worth the Woe?

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 Hospitalfor allowing the use of his material/content in this presentationDr. Yousem’s online lecture series can be viewed at:http://webcast.jhu.edu/mediasite/Catalog/pages/catalog.aspx?catalogId=7e18b7d5-9c63-487e-aaf1-77a86f83b011Dr. 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 reimbursement2 • 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 workload3 • 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 images1 • 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 interpretations4 • 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 notes2

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.