No pattern seen in survey for overreader qualifications.
Nowhere are the dangers of overreliance on computers more obvious than in the interpretation of computer-generated results of electrocardiography. The import of the decisions to be made on the basis of these machine results demand that accuracy and validity be checked. The brain of a human being is required. But beyond the basic need, what are the protocols and qualifications that should be in llace for this overreading task? How, if at all, should the process of overreading differ from that for noncomputer cardiography results?
To determine what other hospitals look for in assigning responsibility for this necessary check, we asked the College to mail a survey to its hospital-based members. We wanted to know the degree to which hospitals have instituted formal mechanisms for the overreading function and what qualifications are sought in the physicians who perform this critical task.
Surprisingly, slightly less than two-thirds of the respondents (60.6 percent) use panels of physicians who bill for overreading computer-generated ECGs. Contracts exist between the physicians and the hospitals in 82.3 percent of the institutions. Only 44 percent of the hospitals report that they require overreaders to be board certified in cardiology. The remaining institutions require board eligibility in cardiology, board certification in internal medicine, or board eligibility in internal medicine, in descending frequency.
A wide range of other requirements for overreaders are mentioned by responding hospitals:
* Member of teaching faculty.
* Successfully complete qualification examination.
* Postgraduate training in ECG interpretation.
* Family practice certification.
* Documentation of training and experience.
* Part of privileging system.
Two hospitals indicated that they had no formal requirements for overreaders. In only 30 percent of the hospitals were the criteria for selection in written form.
We also asked if there were volume or utilization standards for eligibility to serve in an overreading role. In one sense, this would indicate that there was a reward for contributions to the hospital. On the other hand, such a criteria could be read as a quality standard for overreaders. Only about 20 percent of the hospitals indicated that they require physicians to meet a certain percentage of practice or level of volume or utilization at the hospital to be eligible to overread.
Continuing education for overreaders is not a great concern. Only 14.5 percent of the hospitals have criteria for attendance at continuing education programs for overreaders. For some, the hospital itself provides continuing education or arranges for it. Others have minimum continuing medical education credit levels that have to be met. Still another group has some kind of monitoring arrangement in place and requires completion of continuing education programs when standards are not met by overreaders.
While most hospitals seem to have instituted formal arrangements for overreading of computer-generated ECGs, no specific national pattern emerges for the qualifications of these readers. Each institution has evolved its own special criteria and procedures, meeting local demand and using available local resources.
A minimum of board certification or eligibility in internal medicine seems acceptable to the majority of respondents, although many expect board certification or eligibility in cardiology. Other ECG education and a qualifying examination are emerging as useful discriminators in some settings.
Out of this background, and with a great deal of local discussion, we developed a revised set of qualifications and clinical criteria for ECG readers based on estimates of the number of ECGs any reader should read annually to maintain his or her expertise. Given those target numbers, all qualified applicants were considered.
Board certification in internal medicine sas considered adequate but not sufficient. Other criteria required additional ECG-specific education or certification in cardiology. Active staff status was required to encourage application by physicians loyal to the hospital and participating in medical staff affairs.
If there was a tie between two or more qualified applicants, they were ranked according to number of admissions, duration of active staff status, and number of outpatient referrals. New physicians appointed to the panels must be precepted for a number of readings by the medical director for cardiology.
All acceptable candidates chosen to overread must sign contracts that spell out expectations for the physicians and define how billing will take place. Quality assurance guidelines and CME conferences concerning difficult or unusual cases are included.
Pricing was a serious concern of all applicants and of management. Payment for overreading was established on the basis of an analysis of past payment by payer and allowable fees under the various relative value scales in different payer contracts. The hospital bills on behalf of the physicians for ease of administration. Payment to physicians acknowledges bad debts and uncollectibles.
As more hospitals move to formalize reader panels for various clinical tests, surveys such as this one provide valuable information for benchmarking current and proposed practices and policies.
Michael B. Guthrie, MD, MBA, FACPE, is Vice President for Business Development and Keathe A. Singleton is Director of Cardiology, Penrose/St. Francis Healthcare System, Colorado Springs, Colo.
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|Author:||Singleton, Keathe A.|
|Date:||May 1, 1990|
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