Medical Imaging Critical To Improving Emergency Care: Q&A With Dr. Sandra Schneider Part 3

2013-04-25
 

Dr. Sandra SchneiderEarlier this week, emergency medicine specialist Dr. Sandra Schneider identified emergency department overcrowding as a symptom of hospital overcrowding in part one of my interview with her.  In part two yesterday, we identified better collaboration between medical imaging and emergency care leaders as critical towards managing overcrowding.

In the final part of my interview below, we put our focus squarely on the patient, as we learn how all of medicine must work together to improve the cost efficiency of care, without sacrificing improvements to patient outcomes.

How do you see the new focus on improving patient outcomes impacting emergency medical care and/or reimbursements?

SS: Providers have always been interested in the outcome of their patients. Quality measures are simply one mechanism to assure that focus. As a patient care is now often quite complex, involving many well trained, intelligent providers, quality measures should never be developed by one specialty that involves care provided by another. Radiology should not dictate when medical images are preformed in the ED, nor should emergency physicians dictate timing for final attending interpretation of those studies. The development of these quality measures must incorporate all stakeholders.

The largest identified area of potential savings in healthcare is that spent on defensive medicine. Without safe harbor, clinicians will continue to order many tests in order to have a zero miss rate. Radiologists will continue to suggest advanced medical imaging of innocent appearing nodules in order to have their own zero miss rate.

Medicine, all of medicine, needs to work toward reforming our medical liability system so that screening tests with a very high sensitivity will be an acceptable standard of care. Unless there is safe harbor afforded those who follow established national guidelines for care, we will not be able to curtail utilization, cost and radiation exposure. Medical imaging, which plays a central role, would be a natural leader for such an effort.

Patient satisfaction is an important measure of quality and is now measured in nearly every department. Patients often present to the emergency department anticipating advanced testing and imaging. Many patients are sent to the emergency department by their PCP with specific instructions to have a CT scan or MRI. Others have been advised to have such testing by their friends or recent media reports. While the emergency physician may attempt to dissuade the patient from such testing, these attempts are largely unsuccessful and lead to intense patient dissatisfaction.

Emergency care interfaces with nearly all specialties of medicine. We have important outreach in the community through our ties with EMS. We have facilities that are staffed 24/7/365 that can be used to close the gap for patient follow-up. There may be cost savings to the institution to utilize our excess space during down times to see patients who cannot see their PCP. Under an ACO it may be prudent for all patients with acute unscheduled visits to be seen within the ED facility. Forwarding thinking institutions are incorporating ED leadership into care models in innovate ways.

What necessary evolutions in medical imaging have you seen, or expect to see come about, in response to health care reform?

SS: There will be increasing pressures to reduce cost, reduce radiation, improve patient outcomes and increase patient satisfaction. Two of these are possible, three difficult, but all four will be a challenge. Patients perceive extra value in visits that include testing, especially advanced imaging. There is an increased degree of patient confidence if the diagnosis is based on a CT or MRI. Equally important, advanced imaging does improve outcome. Appendectomy rates are down, thrombolytic treatment for stroke is only possible because of medical imaging, and countless lives have been saved because of imaging of a subarachnoid hemorrhage and pulmonary embolism. Trauma care has been significantly improved and countless unnecessary surgeries avoided because of rapid, highly sensitive CT scans.  But radiation is a serious issue for our future, particularly in children. MRI can be substituted in many cases, but at a much greater cost. The challenge for medical imaging is to retain the accuracy of its testing while reducing radiation and cost, and increasing availability.

Medical imaging is a critical part of patient assessment. In the future, this role will increase as our ability to detect and visualize disease increases. Forty years ago, grainy CT images of the brain gave us our first glimpse of cerebral bleeding. Now CT, MRI and PET scanning provide us evidence of the structure and function of the brain. It is likely that medical imaging in the future will help us identify some of the diseases we struggle with today, such as sepsis, mental illness and perhaps even pain. Advancing the care of patients will necessitate a collaborative approach to research and clinical care throughout all medical specialties. Radiologists and Emergency Physicians working together with mutual respect and transparency on a national and local level would be an important first step.

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