Top Three Reasons to Love Peer-to-Peers

Readers of this blog will know that we’ve been posting a series of tips on how to minimize the complexity of the prior authorization system. In our series of posts under the heading “How to avoid peer-to-peers,” we’ve been coaching you on how to best prepare before you initiate the prior authorization process.

So now you might be thinking, “what’s up with this post?”

Trust us —it’s not a contradiction. Our primary goal has always been to make sure that each patient gets the right treatment or test and at the same time we want to simplify and streamline prior P2P-animatedauthorizations, So our commitment to modernizing prior authorization includes the proviso that it will not compromise our focus on that primary goal.

What is the purpose of a peer-to-peer conversation with one of our physicians? It’s precisely to ensure that the evidence-based guidelines that your medical staff applies every day are discussed in relation to your particular patient, when that is deemed advisable. So, having said we want you to avoid unnecessary peer to peers, in the event one is required, here are the top three reasons why you should love peer-to-peer conversations:

1. They’re educational. 

Each participant will learn something from a peer to peer. The eviCore physician will get a better understanding of the specific patient circumstances and rationale behind the order. The ordering physician might learn about recent studies in the field and how an alternative approach might be more beneficial. New evidence, research, and study findings emerge nearly every single day, and these sometimes influence our guidance on how patients should be treated. This is one of the key reasons why eviCore offers peer-to-peer conversations—to help educate providers on up-to-date information that will promote better outcomes for the patients’ health.

2. They facilitate provider collaboration. 

eviCore recognizes that there is an actual patient associated with each case, and that’s why we assign a physician to review each one. Peer-to-peer conversations allow clinicians to have a discussion about that patient. The ordering provider provides the patient’s medical history, symptoms, and examination results to the conversation, and the eviCore physician is able to lend his/her own professional experience, along with easy access to and knowledge of the most current clinical guidelines.

In combination, eviCore’s physicians bring expertise in all the specialties related to our solutions, and are licensed in every state of the union. Our policy is that when a requesting provider asks to speak to a like-specialty reviewer, eviCore makes such a person available in every case. The requesting provider will gain access to an eviCore specialist who has been rigorously trained in appropriate utilization and is knowledgeable in the specialty and understands the appropriate patterns of diagnosis and treatment.

3. They explain the application of the clinical guidelines. 

The eviCore clinical guidelines reflect various clinical support content, such as: the risk factors for conditions, diagnostic criteria, prognostics with and without treatment, the benefits and risks of various treatment options, resources associated with different diagnostic or treatment options, and patients’ experiences of the options.

In addition, during a peer-to-peer conversation our physicians, who are well-versed in the clinical guidelines, can provide background information as to why a case is being reviewed or why an alternative treatment recommendation was made.

To summarize: yes, peer-to-peer phone calls take time out of your extremely busy day. And we understand that usually they are something that you would prefer to avoid. But should you find yourself on a peer-to-peer phone call, remember that it can offer real benefits—to your case analysis as well as to your understanding of the specialty—so your time will likely be well spent.​

Medical Testing: One Thing Leads to Another

​In an ideal world, every single medical test ordered would be appropriate and necessary. But in our imperfect world, that’s pretty much an impossible goal.

In fact, in the worst-case scenario, when a healthcare professional orders an unnecessary test, he or she might end up initiating what’s called the “cascade effect.” That is, one unnecessary test leads to another (possibly questionable) test, which may lead to a diagnosis and subsequent treatment that may not have been necessary and can be actively harmful to the patient. Think of a snowball rolling down a hill. It starts off as a tiny orb, but by the time it gets to the bottom of the hill, it’s huge—and maybe unstoppable.

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Test Time? Not So Fast…

First, do no harm. (Hippocratic Oath, 100 BC)

That’s the vow that doctors make when embarking upon their careers. All clinicians would agree that they want to reduce the likelihood of their patients being unnecessarily exposed to potentially harmful substances. Increasingly today, however, they may be inadvertently exposing their patients to unnecessary potential risks by ordering certain kinds of tests, or ordering these tests too often. Sound decisions about ordering a particular type of test require understanding of the accompanying potential risk versus any potential benefit for the patient. A clinician must consider which option is best for each patient’s clinical circumstances, and one of the most useful tools for making that judgment call is a relevant set of evidence- based guidelines.

During a recent presentation at the Tennessee chapter of the American College of Physicians’ Scientific Meeting, eviCore assistant medical director Dr. Robert Neaderthal spoke about the importance of using evidence-based guidelines to help weigh the risk-benefit ratios of various types of imaging tests. Consider the use of Computed Tomography (CT), for which the technology has significantly evolved over the past 40 years. Modern CT scans require less time, and the resulting images are highly detailed and far more accurate than those of the older CT technology.

However, this use has posed both potential benefits and risks. According to the U.S. Food and Drug Administration (FDA), the main risks connected with the use of CT scans are “those associated with test results that demonstrate a benign or incidental finding, leading to unneeded, possibly invasive, follow-up tests that may present additional risks and the increased possibility of cancer induction from x-ray radiation exposure.” The “effective dose” is used to compare the risk estimates associated with radiation exposure. These effective dose estimates may vary based on the type of procedure, patient size, equipment, and techniques. Using average effective doses, it has been estimated that a chest CT scan may have an effective dose equivalent to that of 350 frontal-view chest x-rays. Furthermore, if the clinician decides to order a CT without contrast and another with contrast, the radiation dose may be doubled. Clinicians must analyze each patient’s situation and ask: Is an imaging procedure necessary at this time? If so, which procedure will best meet the patient’s diagnostic needs while avoiding any unnecessary exposure to potentially harmful substances such as radiation and contrast material? Evidence- based guidelines such as eviCore’s Cardiac Imaging Guidelines and Chest Imaging Guidelines can provide valuable insight based on sound scientific data, and that insight can help clinicians be more confident in their decision-making.

Another example that Dr. Neaderthal highlighted is the nuclear stress test, which is often used to evaluate patients with chest pain or other symptoms that may be caused by coronary artery disease (CAD). Though nuclear stress tests using thalium or sestimibi radioactive tracers are commonly performed, there are several other options available, such as a treadmill exercise test, stress echocardiogram, or stress cardiac MR. These other options have been shown to be equally effective in the evaluation of these cardiac symptoms, depending on the clinical presentation of the patient. And, these other options do not involve the risk of radiation exposure.

Importantly, the decision of which test to perform should be based on the individual patient, the clinical presentation, and an assessment of the patient’s risk for CAD. For example, in young patients or those with a low predicitive likelihood of having coronary artery disease, a simple treadmill test that is negative (normal), makes the odds of coronary artery disease extremely low.

Clinicians should consider all the information that is available to them, including their patient’s medical history, physical findings, the likelihood of a given disease entity causing the presenting issue, as well as the current professional guidelines. The physician will need to then decide if there is solid scientific support for ordering an imaging test and, if so, consider using a lower risk alternative.

Whether a clinician is considering an imaging test for screening or specific diagnostic purposes, the basic approach should be the same. Many of these tests have the potential to expose their patients to additional risks, and clinicians should ask themselves if the proposed tests are necessary. In the end, the alternative approach may be beneficial to the patient in more ways than one.

Visit eviCore.com for more information.

Why I’m Writing: Removing the “Gumption Traps” for Clinicians

My mission here is personal. Making it easier for clinicians to find the patient data they need to make sound medical decisions became a personal mission for me one day in 2004, and I’ve been on that path ever since. Back then I was (and still remain) a practicing radiologist. I had completed the curriculum of medical school, residency, fellowship and grueling exams to interpret medical images and perform invasive procedures. I’m also a geek: I love software and have written lots of it. I’m enthusiastic about both clinical practice and computing. But one Spring day in ’04, I began to interpret an abdominal-pelvic CT scan and ran into what the author Robert Pirsig once called “a gumption trap”—a set of obstacles that detract from one’s enthusiasm and ability to perform quality work. 

I was tasked with reading the scan on a patient who had a long and complex history of cancer, marked by multiple treatments, successes and set-backs. However, the clinical information presented to me as the ‘history’—the reason for performing the scan—was woefully limited: a typo-filled one-liner entered by a well-meaning but non-clinical administrative assistant. Further, the source of context and clinical narrative on the patient—the electronic health record—was organized by file date and by kind, but not by the clinical concepts I needed to query. I could easily look for all labs and notes submitted on a given day. But I couldn’t ask the software, “has this patient ever had evidence of distal metastases?” To answer that question—which is what my clinical job required—I would have to manually trove through lots of notes and reports. This was an obstacle. And I was under the gun.

‘Under the gun’ here means the strain that most clinicians experience firsthand, every day they practice. Healthcare is demanding and expensive. The waiting room is almost always full and the tests and procedures we perform lead to bills rapidly totaling thousands of dollars. How well I performed as a physician had a direct impact on that expenditure and I personally felt an obligation to justify my own contribution to that expense. Clinicians of all stripes are expected to deliver meaningful contributions promptly, reliably, and above all, efficiently. In my case that day: read, interpret, dictate…then onto the next case.

In response to frustration, I dreamed for a moment. I thought, “there ought to be a widget that organizes the information the way a clinician needs to think about a case…”. Silence. Being a geek, I imagined what such a software system might do and how it might be composed. The story of what happened after that day—growing a “google for the medical record”, helping to found QPID Health, a company that brought this software to market, and then in the last year joining forces to address medical decision-making at scale with eviCore—will inform what I share with you in this forum.

But one thing has become clear: the problems associated with that day in 2004 remain pertinent to improving health care now. How healthcare data—records, guidelines, and assessment of appropriateness and risk—flow through the conversations taking place between patients and clinicians remains critically important for the delivery of high quality, appropriate, and efficient care. The software tools and services currently available must continue to adapt to the demands and workflow of current care delivery. We have made progress—at least more of the information is now electronic—but clinical medicine is still rife with gumption traps and there is much opportunity for us to innovate.

Recently, the AMA released a set of 21 points to improve one common aspect of clinical decision-making—prior authorization. From the standpoint of clinicians and patient advocates, there is much to consider in this document and much to embrace. Decrease hassle. Keep the external reviews timely and relevant. In a phrase, when a burdensome process isn’t absolutely necessary, get out of the way. At the same time, much more in the way of useful tools and information could be offered to clinicians in the moment to contribute constructively to their conversation and activity. Actionable guideline information. Transparent economic and risk information for patients.

The road map of opportunity is big and wide and this story will be an exciting one. Much will again revolve around information: data gathered and insights delivered promptly and in a way that supports the experience of providers and patients. The goal remains the same: improving the efficiency and quality of the care delivered.

Author: Dr. Mike Zalis

Dr. Mike Zalis is a board-certified Radiologist with extensive experience and expertise in abdominal imaging, interventional radiology, computer science and clinical research. His deep knowledge of what clinicians need to practice most effectively and his ability to translate those needs into software solutions inform QPID’s development. He initiated and directed the QPID Informatics Group at MGH and is also an associate professor at Harvard Medical School. In addition to his work with QPID, Dr. Zalis continues to serve part-time with MGH Interventional Radiology. He holds a BA in Biophysics from the University of Pennsylvania and an MD from University of Virginia, and was a visiting scholar at Stanford University.  

Tip #4: “How can I Avoid Peer-to-Peer Phone Calls?”

Before becoming a medical director 8 years ago, I practiced general internal medicine in a solo practice in Nashville, Tennessee. My first realization upon making the transition to a medical director was how useful eviCore’s evidence-based guidelines were. I remember thinking “Gee, I wish I had known of these guidelines all those years when I was practicing medicine…How helpful they would have been!”

Not only are eviCore’s evidence-based guidelines well organized and updated annually, they are also concise, easy to read, and well-referenced. That first year as a medical director, I told one of my associates from my prior life in clinical practice about the guidelines and how useful they could be in avoiding denials and peer-to-peer calls. Once he discovered how valuable they were, he told me that he felt he’d found “the keys to the castle” and remarked that they were truly eviCore’s “best kept secret!”

In fact, eviCore’s guidelines are not a secret at all. They are free to access and download any time from eviCore’s website. Since the guidelines are published in PDF, you can save them to your own system for reference at any time. Uncertain about the best imaging study for your patient with abdominal problem? Is it an ultrasound? Or is it a CT or an MRI or an MRCP? For periumbilical pain, should you request imaging of the abdomen, or pelvis, or both? If an ultrasound shows a liver mass, should you request a noncontrasted CT, a contrast CT, or both? eviCore’s guidelines are a valuable reference whenever you need direction on the most clinically appropriate and cost-effective next step in treating your patient. 

One question I often get asked during peer-to-peer calls is what sources we use for our guidelines. We use a rigorous process of accumulating and assessing the best available evidence, in accordance with the standards of our accreditation agencies (URAC and NCQA). In short, each chapter in the eviCore guidelines reflects the most current and authoritative evidence-based recommendations created by well-respected national organizations and made available to the public. Primary care and specialty organizations such as the American College of Physicians, American Academy of Family Medicine, American College of Cardiology, American College of Radiology, NCCN, and American Academy of Sleep Medicine create thousands of pages of guidelines and appropriateness criteria that cover diagnosis and treatment. eviCore extracts from those guidelines the criteria that deals specifically with imaging and compresses national guidelines into a single document of less than a thousand pages. This allows the eviCore guidelines to be a very concise reference that providers can access while in the process of seeing patients. While it is unlikely that you will need to look at guidelines with every requested imaging study, it is comforting to know they are available in cases of uncertainty. 

I often invite providers to download eviCore’s guidelines and use them whenever they wish. Some physicians tell me they usually refer to UpToDate, or another well-respected reference. Some tell me they just call a radiology colleague whenever they are uncertain. I invite them to compare these methods with using eviCore’s guidelines and then decide which is faster and more convenient. 

Take Home Point #4: Not only are eviCore’s guidelines no secret, they are your readily available “keys to the castle.” Download them, keep them on your desktop, and refer to them whenever you are uncertain. Use them when you want to get prior authorization “right out of the gate” and avoid denials and peer-to-peers.

The path to the eviCore guidelines on eviCore.com:

www.evicore.com – Clinical Guidelines and Forms – Clinical Guidelines – Cardiology & Radiology – PDFs 

Author: Robert L. Neaderthal, M.D.

Robert L. Neaderthal, M.D. has been a medical director at eviCore healthcare for 8 years. Prior to joining eviCore, he served for 30 years as a primary-care internist in Nashville, Tennessee. Since joining eviCore, Dr. Neaderthal has been committed to helping other providers avoid peer-to-peers by educating them on ways to avoid denials.

For more tips on how to avoid peer-to-peer phone calls, read our other tips as part of the “How Can I Avoid Peer-to-Peer Phone Calls” series here. For questions regarding this topic, please email onlineinfo@evicore.com.