Monday, December 29, 2008

More Alphabet Soup

"ACC/AHA/ACR/ASE/ASNC/HRS/NASCI/RSNA/SAIP/SCAI/SCCT/SCMR/SIR 2008 Key Data Elements and Definitions for Cardiac Imaging"

I could not make those initials up. This was the title of the recently published paper in the Journal of the American College of Cardiology from the writing committee organized to develop clinical data standards for cardiac imaging.

ACC = American College of Cardiology
AHA = American Heart Association
ACR = American College of Radiology
ASE = American Society of Echocardiography
ASNC = American Society of Nuclear Cardiology
HRS = Heart Rhythm Society
NASCI = North American Society for Cardiovascular Imaging
RSNA = Radiological Society of North America
SAIP = Society for Atherosclerosis Imaging and Prevention
SCAI = Society for Cardiovascular Angiography and Interventions
SCCT = Society of Cardiovascular Computed Tomography
SCMR = Society for Cardiovascular Magnetic Resonance
SIR = Society of Intervential Radiology

Wow, that's a tour-de-force of cardiac imaging specialists.* These are smart men and women who understand how the Medicare payment game is paid played. They understand that data, lots and lots of data, in fact, so much data that your head will spin, is the way to assure Medicare payment. In short: gather lots and lots of data, any way you can, to assure the folks on the Hill that you are really serious about showing the cost effectiveness of all of this testing:
The ACC and AHA recognize the importance of the use of clinical data standards for patient management, to assess outcomes, and conduct research, and the importance of defining the processes and outcomes of clinical care, whether in randomized trials, observational studies, registries, or quality improvement initiatives. Hence, clinical data standards strive to define and standardize data relevant to clinical topics in cardiology, with the primary goal of assisting data collection by providing a platform of data elements and definitions applicable to various conditions. Broad agreement on a common vocabulary with reliable definitions used by all is vital to pool and/or compare data across studies and assess the applicability of research to clinical practice. The growing adoption of electronic medical records renders an even more imperative and urgent need for such definitions and standards. Therefore, the ACC and AHA have undertaken the task of defining and disseminating clinical data standards—sets of standardized data elements and corresponding definitions to collect data relevant to cardiovascular conditions. The ultimate purpose of clinical data standards is to contribute to the infrastructure necessary for accomplishing the ACC/AHA’s mission of fostering optimal cardiovascular care and disease prevention.
On the surface, these efforts seem like the best way to begin to get a handle on the cost-effectiveness of cardiac testing. No doubt the shear volume of data generated will be heretofore unmatched and a rich source of research grants for academe for years to come.

But tied to each of these data element sets created for every cardiac imaging test, is the requirement to include as an "administrative" data element the patient's insurance information. The writing group explains this data-element necessity as a means to "foster optimal cardiovascular care and disease prevention" because:
The insurance payer element was included to be certain that patients of all payer status were included in studies equitably, especially those funded federally (ed: emphasis mine). The inclusion of this data was not to in any way suggest that cardiac imaging patients should be screened on the basis of ability to pay.
Yep, it's all to justify to the Medicare National Bank that, yes sir, we really DID need this test. While the test might be ordered irrespective of the ability of the patient to pay as the writing committee suggests, for the first time we will be granting insurers direct automated line-item access to clinical information and the test results. The implications of this are concerning.

Imagine, line item data on your renal function, ejection fraction, stress test results, cardiac risk factor analysis - all instantly available to an insurance company's computer database and conveniently entered unwittingly by the echocardiography clerical staff in the hospital of your choice. Imagine the next time you then go to purchase insurance. Best of luck to you.

Or imagine you are a doctor without an electronic medical record and ordering system - best of luck to you as you complete the test-request form that will soon look more formidable than the MCAT bubble answer sheet used to qualify for medical school. Remember to use a number 2 pencil.

Or consider if a clerical error is made during data entry: what recourse will you have? Will you have the option of editing the data entered to assure insurer payment for the test they claim was not appropriate because four data fields were left blank? "Sorry Mr. Jones, on the basis of a creatinine of 1.6, and four empty data fields on the ordering questionnaire, this test should not have been ordered, so * b-o-o-i-i-n-n-g-g *, we're not going to pay for that test after all."

But in this era of "evidenced-based medicine," these convoluted, complicated, and thoughtfully-produced-but-arbitrary data forms (Note: 20 pages were devoted in the article just for the medical history fields alone. And what is an "equivocal" test anyway?) are being feverishly developed by these cardiac imaging societies. They must justify continued testing and Medicare payments on the basis of a promise of future as-yet-undeveloped studies based on retrospective utilization data completed by the non-medical clerks at the time of test ordering. And thanks to hoards of well-meaning academics that are eager to secure more grant funding, this same dubious retrospective data will soon serve as paradigms upon which our treatment and further testing "guidelines" will be based.

But retrospective data collection like this is far easier and less expensive to gather rather than a prospective, randomized trial. Who needs those?

Heck, I guess I should stop complaining.

After all, I am a cardiologist.


* The conflicts of interest of the authors of this document warrant notice. They are not insignificant - so much so that the article reviewers conflicts were also disclosed as an appendix to reassure a more "non-biased" critical review of paper occurred.


"ACC/AHA/ACR/ASE/ASNC/HRS/NASCI/RSNA/SAIP/SCAI/SCCT/SCMR/SIR 2008 Key Data Elements and Definitions for Cardiac Imaging." J Am Coll Cardiol, 2009; 53:91-124, doi:10.1016/j.jacc.2008.09.006 (Published online 8 December 2008).

1 comment:

Anonymous said...

This will be so much easier once ICD-10 is implemented. NOT!

Including patients' nsurance information = delay 'em and deny 'em.