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.

Tip #3: How can I Avoid Peer-to-Peer Phone Calls?

In our first two blog posts on how to avoid peer-to-peer (P2P) phone conversations, we shared some tips on how to make the process of obtaining prior authorization easier and more efficient for clinicians and administrators. The best way to avoid denials, appeals, and P2P phone conversations is to obtain prior authorization “right out of the gate” when your office’s prior authorization employee (PAE) makes the initial request for an approval number. During the initial request before the case is submitted, is the best time to thoroughly gain an understanding of the evidence-based guidelines eviCore uses to determine medical necessity, reference the quick reference tools available, and verify that all documentation validating compliance is complete. Our goal in these blogs is to provide you with the tips, tools, and other necessary information to make the process easier for everyone.

One important tip is that utilizing the eviCore web portal is the fastest, easiest, most efficient way to obtain prior-authorization. While it is important to have all the relevant information prepared prior to initiating a request, utilizing the website takes approximately 3-5 minutes, as opposed to speaking with a representative on the phone.

Here is how our prior authorization process works, using an example of an imaging study.

When the PAE contacts eviCore to request a case or initiates a case through the web portal, our phone representative conducts a quick identification. We identify the patient, the insurance company, the imaging facility, the imaging study, and the reason for the request. With this completed, the case has the potential to be auto-approved after minimal information is provided. If the case is not auto-approved, the PAE is transferred to a nurse reviewer who then asks a series of relevant clinical questions.

eviCore uses an automated decision support system that analyzes the PAE responses to the clinical questions. At times, the system will approve the request based on only a few of the responses. Other times, the nurse reviewer will enter all of the clinical responses into the patient’s data base. While the nurse is typing the answers, he/she is also comparing the responses to eviCore’s evidence-based guidelines seen on another computer screen.

There is nothing magical or secretive about the clinical questions. They are the “who, what, when, where, and how” questions that most providers were taught in school: “What is the problem (e.g., pain, swelling); when did it begin; where is the problem located; how did it occur (e.g., injury, fall, trauma)? The nurse reviewer may also ask if any other imaging studies (x-ray, ultrasound, ECG) have been completed; when the patient sought treatment; what kind of treatment was given; and how long the treatment lasted. For many suspected diseases, the typical questions are available on the eviCore website.

It’s important to understand that eviCore intake nurse reviewers are able to approve any imaging study requested, but they are not authorized to deny any study. If the clinical responses meet the guidelines, the nurse can approve the request immediately and issue a Prior Authorization (PA) number. If the responses do not meet the guidelines, the nurse specialist must pass the case on to one of our medical directors for review. For example, if the guidelines call for a plain x-ray before a CT chest and the PAE does not have the result of the x-ray, the nurse specialist cannot approve the request and will then send the case to a medical director.

Once a medical director reviews the case, his or her options include:

1. Approving the request.

2. Denying the request and providing a reason for the denial.

3. Denying the request and providing an alternative recommendation (alt-rec) – a reason must be given as well.

The difference between a denial and an alt-rec is simple. The alt-rec denies the requested study but offers an alternative imaging study that eviCore will approve. For example, the alt-rec may indicate, “We cannot approve the CT chest without and with contrast, but we will approve a CT chest with contrast only.”

If there is a denial with an alt-rec, eviCore will call your office and offer the alternative imaging study. If it is accepted, the denial is overturned, a PA number is issued for the alternative study, and that number is given to your office staff.

If there is a denial where an alt-rec is declined by the provider’s office, an array of appeals and reconsiderations are allowed, all of which require submission of additional clinical information. The most time-consuming of the appeals involves conducting a P2P phone call, in which a provider must speak on the telephone with a medical director. Again, the P2P may result in upholding the denial; issuance of a different alternative recommendation; or the denial may be overturned and approved, based on the exchange of clinical information between the provider and medical director.

Take Home Point #3: The fastest and most reliable way to avoid P2P phone calls and other appeals and obtain the prior authorization number “right out of the gate” on the very first submission is to be prepared to answer the clinical questions that will be asked.


Author: Robert L. Neaderthal, M.D.

Robert L. Neaderthal, M.D. has been a medical director at eviCore healthcare for seven 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.

Clinical Guidelines: a Brief History

Clinical guidelines advise healthcare professionals about the most appropriate treatment or care for people with a particular condition such as lower back pain or cancer. Informally, clinical practice guidelines have been a fundamental component of medicine since healers first discussed how best to manage patients.

The first known formal clinical guidelines may have been written by Hippocrates. Credited with advancing the systematic study of clinical medicine, he summed up medical knowledge and prescribing practices for physicians in the Hippocratic Corpus, works written for both specialists and lay people, sometimes from opposing viewpoints. This library of medical text written between the sixth and fourth centuries BCE probably contained the earliest clinical guidelines.

The modern age of guidelines began with a 1992 Institute of Medicine (IOM) report, which defines guidelines as “systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances.” Now there are numerous guidelines produced by medical societies (such as the American College of Cardiology) or governmental bodies (such as the Agency for Healthcare Research and Quality).

Who Participates in Clinical Guideline Groups?

The individuals appointed to devise—or update—clinical guidelines include healthcare professionals, researchers, patients and caregivers. All have specific knowledge of the clinical domain. In addition, this collaborative approach to guideline development ensures that best practices from a variety of settings and viewpoints are incorporated to produce the best outcomes for patients.

The initial development of guidelines typically includes the following steps:

  • Identify and delineate the subject area (e.g., cancer, back pain)
  • Convene and lead a guideline development group made up of subject-matter experts
  • Assess evidence about the clinical question or condition
  • Translate evidence into a recommendation
  • According to the Institute of Medicine Standards for Developing Trustworthy Clinical Practice Guidelines, for each recommendation, the following should be provided:
    • An explanation of the reasoning
    • A rating of the level of confidence in the evidence underpinning the recommendation
    • A rating of the strength of the recommendation by utilizing a scale such as the one developed by the American Academy of Family Physicians
    • A description and analysis around any differing opinions regarding the recommendation
  • Review the guideline by utilizing systematic reviews approved by the Institute of Medicine Committee’s Systematic Reviews of Comparative Effectiveness Research.

Guideline development groups (GDG) must have the time, resources, and skills to scrutinize evidence and make objective value judgments based on their expertise, clinical studies on the subject matter, and analysis of the medical evidence available to them. Group members must be free of conflicts of interest, and are required to declare all interests and activities resulting in any potential conflicts of interest by written disclosure to those convening the GDG. Some ideal characteristics of groups that author these clinical guidelines are that they are multidisciplinary, and gender and geographically-balanced.

The group will appoint a writer as well as a chair, who should be an expert facilitator. Many groups include a methodologist, an expert in guideline development process to ensure that the standardized articulation of recommendation is met, and an economist, who can advise on economic benefits and drawbacks of recommendations.

What Do Guidelines Include?

Guidelines include various clinical support content, such as the risk factors for conditions; diagnostic criteria; prognostics with and without treatment; the benefit and harm of various treatment options; resources associated with different diagnostic or treatment options; and patients’ experiences of the options.

The 1992 IOM report suggested that every set of clinical guidelines also include information on the cost implications of alternative, preventative, diagnostic, and management strategies for each clinical situation.

Guidelines are required to use clear language. Vague or nonspecific wording should be avoided, as clinicians may have difficulty knowing the precise contextual meaning of phrases such as “clinically appropriate” or “if necessary.” The manner in which guidelines are developed and funded must also be transparent and publicly available. As each new guideline is developed, it is important to ensure that all relevant external stakeholders have reviewed the guidelines prior to publishing.

Additionally, guidelines, created to improve patient care, must be updated as new research emerges so they do not lose their clinical relevance.

Tracing the Path and Significance of Prior Authorization

Health insurers require prior authorization (PA) for certain healthcare services, treatment plans, prescription drugs, and/or durable medical equipment before a patient can receive them. The determination focuses on whether the service, drug, or product is medically necessary. It does not guarantee that the insurer will cover the cost.

The PA process—and research into its effectiveness—dates back more than 25 years, when states began analyzing how to curtail drug costs within the Medicaid program. The Omnibus Budget Reconciliation Act of 1990 included PA among explicit provisions for limiting drug coverage and cutting costs. The legislation also required the Health and Human Services Secretary to study the impact of PA programs on beneficiary and provider access to prescription drugs as well as on program costs, and to make recommendations for PA reforms if needed.

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