IHI Expedition Eliminating Overuse in Medical Imaging Jim Duncan, - PDF document

2/18/2014 Wednesday, February 19, 2014 These presenters have nothing to disclose IHI Expedition Eliminating Overuse in Medical Imaging Jim Duncan, MD, PhD Kelly McCutcheon Adams, LICSW 2 Expedition Coordinator Kayla DeVincentis, CHES, Project Coordinator, Institute for Healthcare Improvement, currently manages web-based Expeditions and the Executive Quality Leaders Network. She began her career at IHI in the event planning department and has since contributed to the State Action on Avoidable Rehospitalizations (STAAR) Initiative, the Summer Immersion Program, and IHI’s efforts for Medicare-Medicaid enrollees. Kayla leads IHI’s Wellness Initiative and has designed numerous activities, challenges, and educational opportunities to improve the health of her fellow staff members. In addition to implementing the organization’s first employee health risk assessment, Kayla is certified in health education and program planning. Kayla is a graduate of Northeastern University in Boston, MA, where she obtained her Bachelors of Science in Health Science with a concentration in Business Administration. 1

2/18/2014 3 WebEx Quick Reference Welcome to today’s • session! Raise your hand Please use chat to “All • Participants” for questions For technology issues only, • please chat to “Host” WebEx Technical Support: • 866-569-3239 Dial-in Info: Communicate / • Join Teleconference (in Select Chat recipient menu) Enter Text When Chatting… 4 Please send your message to All Participants 2

2/18/2014 5 Expedition Support All sessions are recorded Materials are sent one day in advance Listserv address: medicalimaging@ls.ihi.org – Sends an email to all participants and faculty – Use only for questions relevant to all participants – To add yourself or colleagues, email us at info@ihi.org Where are you joining from? 3

2/18/2014 7 Expedition Director Kelly McCutcheon Adams, LICSW has been a Director at the Institute for Healthcare Improvement since 2004. Her primary areas of work with IHI have been in Critical Care and End of Life Care. She is an experienced medical social worker with experience in emergency department, ICU, nursing home, sub- acute rehabilitation, and hospice settings. Ms. McCutcheon Adams served on the faculty of the U.S. Department of Health and Human Services Organ Donation and Transplantation Collaboratives and serves on the faculty of the Gift of Life Institute in Philadelphia. She has a B.A. in Political Science from Wellesley College and an MSW from Boston College. 8 Today’s Agenda Your stories about overuse and good decisions Measuring overuse Action period assignment 4

2/18/2014 9 Expedition Objectives At the end of this Expedition, participants will be able to: List common examples of medical imaging overuse Explain strategies for reducing overuse in medical imaging Plan tests to make changes in own environment Utilize tools to assess what changes generate improvement 10 Schedule of Calls Session 1 – The Harm Caused by Overuse in Radiology Date: Wednesday, February 5, 1:00 PM – 2:30 PM ET Session 2 – Measuring Overuse Date: Wednesday, February 19, 1:00 PM – 2:00 PM ET Session 3 – Strategies for Eliminating Overuse Date: Wednesday, March 5, 1:00 PM – 2:00 PM ET Session 4 – Measuring What Changes Lead to Improvement Date: Wednesday, March 19, 1:00 PM – 2:00 PM ET Session 5 – Sustaining the Gains Date: Wednesday, April 2, 1:00 PM – 2:00 PM ET 5

2/18/2014 11 Faculty Jim Duncan, MD, PhD, is a Professor of Radiology and the Chief Quality and Safety Officer for the Mallinckrodt Institute of Radiology at Washington University School of Medicine. He maintains a clinical practice in interventional radiology and divides his time between St. Louis Children's Hospital and Barnes-Jewish Hospital in St. Louis. Dr. Duncan works on multiple quality and safety improvement initiatives for both local and national organizations. He has a BS from the University of Michigan as well as an MD and PhD in Cellular and Molecular Biology from Washington University. He completed the IHI Improvement Advisor Professional Development Program in 2012. 12 Session 2: Measuring Overuse Choosing a focus for your improvement effort – Your examples of overuse in imaging Measurement strategies – Start simple: Leverage current data sources – Using current performance as a baseline 6

2/18/2014 13 “All Teach, All Learn” What examples of overuse did you find in your organization? How is your organization measuring CT Dose? Tell us about your frontline teams – how are they successfully eliminating overuse or measuring CT dose? 13 14 Starting to Measure Dose per image – Data source: CT Dose Reports Images per study – Dual Scans – Data source – Billing records 7

2/18/2014 15 Poll Questions How are you capturing CT dose information at your site? – Not yet capturing information on CT doses – Manual methods – Mixture of manual and automated methods – Fully automated process – Not sure 16 Capturing CT Doses Steps – CT scan performed – Scanner calculates dose metrics – CTDIvol, DLP – Copy these values into the Radiology report – Which value do we enter into the report? 8

2/18/2014 17 Digression: Metrics versus Intent Intent = preventing cancer – Should be measuring DNA mutations that involve oncogenes Intent = preventing skin injury – Should be measuring cell death at particular skin locations Rare that we measure exactly what we want – Measurements as surrogates – Cancer = radiation dose to sensitive tissues – Skin injury = peak skin dose Possible to learn from imperfect data – Infer the result of interest – Waiting for better data usually just delays improvement 18 Operational Definitions "An operational definition is a procedure agreed upon for translation of a concept into measurement of some kind." - W. Edwards Deming Example: Radiation dose for a Head CT – Need to define process for measuring “radiation dose” – CTDI (CT Dose Index) is “dose/CT slice” measured in a phantom – DLP (Dose Length Product) is CTDI x number of slices – Other measures such as SSDE: size specific dose estimate – Need a process for identifying which exams are “Head CTs” – Names within Radiology Information Systems are not standardized – “Head CT” vs “CT Head” vs “CT Brain” vs “Std Head" – Options: CPT codes, RADLEX, etc. 9

2/18/2014 19 Data Standards in Medical Imaging DICOM : Digital Imaging & Communications in Medicine – International standard: file format analogous to JPEG, TIFF, PNG. Includes numerical values for each pixel as well as metadata – Metadata fields: dose metrics, patient identifiers, date/time, etc. – DICOM files are transferred, stored and viewed using Picture Archiving and Communications Systems ( PACS ) CPT : Current Procedural Terminology – US standard: nomenclature for imaging procedures – 70450 = noncontrast head CT – CPT codes are used by Radiology Information Systems ( RIS ) to order exams, manage workflow, organize reports and bill procedures 20 Man vs Machine Manual (invites human error) – Dictation/transcription errors – Data embedded in reports – Applying rules Assessing compliance – Importance of feedback – Timely – Specific 10

2/18/2014 21 Improvement Cycle 22 Improving Data Capture Automated data capture – Improved accuracy and reliability – Much more detailed datasets 11

2/18/2014 23 Poll Question Where would you go to look up CT doses for a series of patients? – Information is not available – Radiology reports – PACS (Picture Archiving and Communication System) – RIS (Radiology Information System) – Dose database – Not sure 24 Analyzing Data “We are drowning in data, what we seek is knowledge.” Deming 12

2/18/2014 25 Data Analysis Importance of predictive models – Quality = conformance to expectation – Substantial deviation from expectation is an informative event Visualizing data: CT volume at St Louis Children’s Hospital 26 Transforming Data into Knowledge Data vs Information – Data: raw numbers/observations – Information: determined by patterns within the data Knowledge is the ability to predict future events 13

2/18/2014 27 Learning and Knowledge Learning – We learn nothing new about the inner workings of our system when the observed results agree with our expectations Unexpected events are informative – To learn about a system we need to find and study anomalies – Use the new knowledge to manipulate the system so that it fulfills our needs What could have happened in 2005 that turned linear growth into linear contraction? 28 Using Data to Understand the System Possible causes for the observed decrease in CT volume – External forces – Decrease in overall volume? – Importing outside CT studies? Made possible by – DICOM standard – Awareness Image Gently – campaign led to changes in behavior Conversations – about radiation doses from CT 14

2/18/2014 Communication Example Sharing CT dose information with customers – Patients, Referring Physicians, Medicaid, etc. Simplify the conversation – Quality = conformance to expectation – Use predictions as anchors – Teach customers to monitor variation from prediction Lab results as an analogy “But Medicine is Different” “You cannot apply ideas from _________* because people get hurt if we make mistakes” *brewing beer, information theory, statistical process control, … 15