Encounter-based vs. order-based imaging
April 10, 2018
by Sean Ruck
, Contributing Editor
When HealthCare Business News interviewed Dawn Cram, there were a number of questions planned. But the first question, asking where encounter-based imaging stands today, was almost all it took to have an article’s worth of material.
“You’ve just touched on one of my favorite topics. I can speak on this for hours!” Cram replied.
Cram is the IS director, enterprise imaging at Ochsner Health System. For the last few years, she has presented at HIMSS and SIIM on this and other topics. While the interview ran just under an hour, she still provided a wealth of information and thoughts about encounter-based imaging versus order-based.
“Traditionally, we have been an order-based world in imaging,” Cram said. “In radiology, physician places an order, radiology fills that order. Same thing with cardiology – physician places an order, cardiology fills that order.”
Cram said it wasn’t the case in every instance, however. Maybe some additional ultrasound was done that wasn’t a part of the original order, for example.
“Can that be an encounter-based imaging exam? It depends. It depends upon a lot of factors. You have billing that’s a factor...maybe some other issues. Ultimately, it’s important to ask what works best for your environment, for your organization.”
She says a provider might bill against an imaging exam that’s done under an encounter-based workflow – if they have it built in. But the need isn’t too great in cardiology and radiology because the physician controls the primary workflow by ordering the study that the department fills.
“So order-based filling is refined in radiology and cardiology. When you go into other enterprise specialties like neurology or dermatology, or even ophthalmology in some cases, maybe you use encounter-based imaging.”
According to Cram, encounter-based workflow is typically more common in visit-based service lines such as dermatology, wound care smaller organizations or departments or in emergency services and some procedure-based service lines such as surgery.
“You may have a doctor using a smartphone to take images for trauma documentation,” she said. “What are they doing? They’re taking it with their smart device and then scanning it or uploading it within their EMR or document management system for retention.”
The problem is what happens after it’s entered into the system. There’s no information associated with it. It’s just a photo.
An example would be a dermatology patient. On a previous visit, the patient had images taken of three moles. Six months later, the patient returns with concerns that one of the moles has grown. If the indexing was done, the physician can pull up “left forearm mole” to do the comparison. Or, they search through a number of images and hope that the one they need actually exists.
In order to have information associated with the image, that information needs to be manually entered. And manual entry is synonymous with bottlenecked workflow in many cases. Or worse, the manual entry just doesn’t happen.
“If you take a point-of-care ultrasound,” for as another example, “you have specialists running around, starting their scan. In some cases, you need to have those images retained in order to have them reimbursed, but the only thing you might need to do in your clinical note is give some indication that the imaging was done. You don’t necessarily need to place an order as a physician.
“If you’re going and seeing patients and need a quick ultrasound on someone’s port, for example, you’re not going to turn around and find the nearest computer to place an order. You’re just going to get enter the patient’s information and start scanning them. And the idea behind encounter-based imaging is that you no longer have to place an order to be able to find that patient on thea patient schedule on an imaging device, and you no longer have to place an order to obtain information to secure the appropriate clinical information and associate it within the metadata of that image in order to index those images properly in an archive.”
And indexing is all-important since proper indexing is followed by efficient distribution of those images. So, for example, if it’s only known that an ultrasound was done due to very generic and top-level documentation, will the time be spent to see if it’s the abdomen ultrasound you need, or do you just go right to it rather than potentially wasting time looking for an image that might not exist? With encounter-based workflows, however, relativity can be established.
Another example would be a dermatology patient. On a previous visit, the patient had images taken of three moles. Six months later, the patient returns with concerns that one of the moles has changed. If the indexing was done, the physician can pull up “left forearm mole” to do the comparison. Or, they search through a number of images and hope that the one they need actually exists.
So encounter-based imaging can provide benefits to the patient. But what about the physicians?
“At a previous organization, we noted an 82 percent increase in physician satisfaction with encounter-based imaging in dermatology. We went from an over five-minute average time to find prior images and view them to less than 30 seconds. So there was a really significant decrease in the time it took to find the exams,” said Cram.
There’s also a savings story for facilities, since they can free employees from having to download photos and manually index them with patient and exam information.
“That can go from a 40-hour-a-week job to just 10 minutes a week to make sure all the images went in and are accessible,” said Cram.