Download Primary Referred Radiology - Taranaki District Health Board

REGIONAL CLINICAL ACCESS
CRITERIA FOR PRIMARY REFERRED
RADIOLOGY
SERVICE LEVEL ALLIANCE TEAM
RECOMMENDATIONS PAPER
PREPARED FOR: THE MIDLANDS HEALTH NETWORK
ALLIANCE LEADERSHIP TEAM
Author: Jane Hudson
SLAT Chair: Paul Malpass
Version: 3.1
Date: 9 September 2011
1
Document Version
Date
Versi
on
1.0
Change/feedback to date
Name / Role
Developing recommendations
2.2
Review of draft
Paul Malpass SLAT Chair Julie Wilson
Senior Funding Manager
Brett Paradine GM Planning & Funding
2.3
Review of draft
15 July
2.4
Include volumes/projections per
DHB
21&22 July
2.5
3 Aug
2.6
5 Aug
2.7
5 Aug
2.7
8 Aug
2.7
29 Aug
3
Include statement on access to
bone density scans
Include last recommendation
Change implementation SLAT to
EAG
Measure whole of system not just
access criteria
Implement over whole district not
just a pilot site
Include statement re budget
holding
Develop radiology referral form –
not use the generic form
Include timeframe of 2 months for
routine referrals
Support in principle subject to
further evaluation and feedback
Waikato – support in principle
Lakes – support in principle
Other DHBs TBA
Await the implementation plan for
robust debate and consideration
Reword description of routine
referrals
Public/private option to be
included on GP referral form
Change ‘When’ on the
implementation plan to read
‘Delivery Date’ and redo the plan
to reflect e-referrals being
managed by the Midland ISSP
9 Sept
9 Sept
5 Oct
3.1
3.1
1 July
2011
8 July
2011
11 July
Brett Paradine GM Planning & Funding
Julie Wilson Senior Funding Manager
Paul Malpass SLAT Chair
Brett Paradine GM Planning & Funding
Julie Wilson Senior Funding Manager
SLAT
ALT
Regional GMs Planning & Funding
DHB GMs Planning & Funding, CIOs,
COOS, Radiology Clinical Directors
Clinical Governance Group
ALT
Clinical Governance Group
DHBs
ALT
Document Distribution
Name
SLAT
SLAT/ALT
GMs Planning & Funding
DHB CIOs, COOS, Radiology Clinical Directors
When
18 July 2011
25 July 2011
5 August 2011
5 August 2011
2
Allan Moffitt, Chair Clinical Governance Group
ALT
SLAT
Clinical Governance Group
DHBs for sign off
ALT
8 August 2011
29 August 2011
29 August 2011
9 September 2011
9 September 2011
22 September 2011
TABLE OF CONTENTS
1.0 RECOMMENDATIONS IN SUMMARY ............................................................................................ 6
2.0 EXECUTIVE SUMMARY ................................................................................................................. 7
3.0 INTRODUCTION............................................................................................................................. 10
3.1 Background ..................................................................................................................................... 10
4.0 PROBLEM STATEMENT ............................................................................................................... 13
5.0 OBJECTIVES ................................................................................................................................. 13
6.0 HOW WILLTHIS CONTRIBUTE TO MHN ACHIEVING CLINICAL TARGETS? .......................... 13
7.0 LINKAGES ...................................................................................................................................... 14
8.0 FUNDING ASSUMPTIONS ............................................................................................................ 14
9.0 RECOMMENDATIONS................................................................................................................... 16
9.1 Recommendation 1: ........................................................................................................................ 17
Regional access criteria and prioritisation methodology should be implemented ................................ 17
9.2 Recommendation 2: ........................................................................................................................ 17
Set up Implementation Expert Advisory Group (EAG) to oversee implementation, review and rollout 17
9.3 Recommendation 3: ........................................................................................................................ 18
Implementation should be within current radiology budgets ................................................................. 18
9.4 Recommendation 4: ........................................................................................................................ 19
Implementation of access criteria/prioritisation methodology should include electronic referrals ........ 19
9.5 Recommendation 5: ........................................................................................................................ 21
Ability for primary care to directly refer for planned/staged/follow up imaging should be explored as
part of implementation........................................................................................................................... 21
10.0 OUTCOMES / MEASURES .......................................................................................................... 21
11.0 KEY PERFORMANCE INDICATORS .......................................................................................... 21
12.0 RISKS ........................................................................................................................................... 23
12.1 Risks (if recommendations are implemented) .............................................................................. 23
12.2 Risks (if recommendations are not implemented) ........................................................................ 24
13.0 IMPLEMENTATION PLAN AND TIMEFRAMES ......................................................................... 24
14.0 SUMMARY OF ESTIMATED RESOURCES AND GANTT CHART ............................................ 29
15.0 REFERENCES & BIBLIOGRAPHY ............................................................................................. 34
REGIONAL ACCESS CRITERIA FOR PRIMARY REFERRED RADIOLOGY SLAT MEMBERSHIP
53
3
Appendix 1
MIDLAND REGION ACCESS CRITERIA FOR PRIMARY REFERRED RADIOLOGY
Appendix 2
MIDLAND PRIMARY REFERRED RADIOLOGY ACCESS CRITERIA PRIORITISATION
Appendix 3
COMPARISON OF MIDLAND DHB RVUS/EXAMS FOR RANDOM PROCEDURES
Appendix 4
SLAT MEMBERSHIP
4
PROCESS
STAGE 1
STAGE 2
STAGE 3 (A)
Terms of reference
Project Initiation Document
Recommendations from SLAT
(TOR)
(PID)
(Progression to Stage 4 and 5
is on instruction from the ALT)
ALT Sign off Date:
Date sent to ALT for their
information:
ALT Sign off Date:
2 Feb 2011
4 May 2011
21 March 2011
…………………………………
….
……………………….
Stage 3 (B)
Total SLAT report available to
ALT on request
……………………….
Date provided:
25 July & 29 August 2011
………………………….
STAGE 4
STAGE 5
Implementation Proposal
Pricing and Business Model
ALT Sign off Date:
ALT Sign off Date:
5 October 2011
N/A for this SLAT
……………………….
……………………….
5
1.0 RECOMMENDATIONS IN SUMM ARY
Item
#
Recommendation
Decision
Information
Required
1
Recommendation 1:
Agree/Disagree/More Information
Regional access criteria and
prioritisation methodology
should be implemented
2
Recommendation 2:
Agree/Disagree/More Information
Set up Implementation
Expert Advisory Group
(EAG) to oversee
implementation, review and
rollout
3
Recommendation 3:
Agree/Disagree/More Information
Implementation should be
within current radiology
budgets
4
Recommendation 4:
Agree/Disagree/More Information
Implementation of access
criteria/prioritisation
methodology should
include electronic referrals
Recommendation 5:
5
Agree/Disagree/More Information
Ability for primary care to
directly refer for
planned/staged/follow up
imaging should be explored
as part of implementation
6
Does this SLAT link with the MHN Model of Care?
Yes / No
How does this SLAT encourage movement towards the MHN Model of Care?






Improves care for the patient by making it more timely and efficient
Improves primary care referral timeliness
May reduce unnecessary non-radiology ED attendances/specialist first specialist appointments
(FSA)s for imaging
Improves primary /secondary interface
Improves certainty and equity of access for imaging across Midland DHBs
Includes eventual integration with MedTech/BPAC e-referral forms (two way communication)
including booking systems
2.0 EXECUTIVE SUMM ARY
This SLAT has developed access criteria and a prioritisation methodology for primary
referred radiology. This process has been valuable in terms of establishing a way of
prioritising diagnostic referrals which identifies four main groups:

urgent

semi-urgent

routine – as follows:

o
Referrals that meet the access criteria will be accepted if they can be done
within available resources within 6 months.
o
Referrals that meet the access criteria will be declined if imaging is unable to
be delivered within available funding within 6 months.
o
While the acceptance criteria is within 6 months, DHB Radiology Departments
should aim to action accepted routine referrals within 2 months
referrals that do not meet the criteria will be declined.
This work has established a common set of conditions for which it is recommended that all
Midland DHBs prioritise referrals. Previously the basis on which referrals were accepted or
rejected was not always clear to referrers. It is thought that due to capacity or financial
disparities between the DHBs the priority threshold differs. Issues such as population needs,
access to the spectrum of imaging modalities, service sustainability and the impact of private
radiology services need examination
The SLAT has been clear that at this time it is not proposing that these sites reduce activity
to an affordable regional level, or alternatively that larger centres divert funding simply to
match the level of access available at smaller DHBs. The information gathered through
7
collecting data in more comparable ways may however be useful in determining movements
towards increased consistency. This would however need to be weighed up against
competing priorities at a DHB level.
Budget-holding by primary care was discussed. It was thought that this may be a mechanism
to improve referral appropriateness and responsiveness. However it was not progressed by
the SLAT. It may however be an option for consideration as part of Midlands Health Network
locality planning.
Implementation of the access criteria should increase clarity about those services that will be
available; those that will not be available, and those routine referrals where the procedure
‘may’ be available. It should be possible to split the routine referral group into sub-sets to
give greater clarity and direction as to availability of access across the region.
It is proposed that implementation includes the use of electronic referrals from primary care
to DHBs, Firstly in those DHBs with this capability and then being staged to fit with DHB IS
workplans. A 6 month review following implementation will identify fish-hooks to be resolved
prior to any further roll-out
Concurrent with the work from this SLAT there have been real developments within some
DHBs which will impact on movement towards equity of access to primary referred radiology
and clarity around this. These include:

increased activity in Waikato DHB with a particular focus on ultrasound and access in
rural areas outside of district hospital locations.

increased clarity/communications around referrals for which a DHB service is unable
to be provided within a 6 month timeframe and hence must be declined

increased transparency on service delivery activity

understanding of capacity constraints has increased – approaches to this are
expected to develop within regional clinical services planning

establishment of a local Radiology User Group (Lakes DHB) which includes
representation from both primary and secondary clinical staff. The RUG philosophy is
one based on a Clinical Governance framework

Bay Navigator Clinical Pathways Projects covering Cardiology, Respiratory,
Paediatric, and Diabetes. Changes to clinical pathways are likely to have an effect on
access to community referred diagnostic services.
Other factors that have impacted on the SLAT’s ability to determine a regional threshold for
access are:

Maximising health gain in a fiscally constrained environment. The key challenge in
considering consistent regional access criteria for primary referred radiology is the
requirement within the construct that any increases in funding for one service area
need to be offset by reductions in another. An important step in understanding this
8
will be more clarity on volumes and the impact and opportunity costs of not providing
consistent access. These factors will be explored at the 6 month review stage.

Primary referred radiology sits within a package of service options including ACC
funded services and private radiology services. The mix of options in each locality
will impact on the level of expenditure that is required in order to achieve consistent
regional access to primary referred radiology. Any future expansion of service
access will need to consider this mixed model to ensure value for expenditure and
overall maximised health gain.

The mix of private specialist activity may also impact on demand for radiology
services differently across the region. However it is unclear whether private specialist
levels reduce or increase the overall demand for publicly funded primary referred
radiology.
Other initiatives were underway at the same time as the SLAT work was occurring, such as:

Radiology access criteria are beginning to receive increased national focus. The
work that has occurred within the SLAT is a step towards this, and has enabled some
of the challenges to become clearer as the national process develops.

A clinical radiology network is likely to be developed for the Midland region
Standardisation of reporting
Initial feedback has been sought from DHB General Managers of Planning & Funding, Chief
Operating Officers, Chief Information Officers, Radiology Clinical Directors and Chief
Medical Advisors. An opportunity was offered to identify the RVU to be used in order to
ensure consistency of measurement across the region, however to date this advice has not
been received.
The RVU1 definition as specified in the MOH data dictionary is: “An individual
operative/diagnostic/assessment procedure completed according to the Royal Australian
and New Zealand College of Radiologists definition for RVUs and codes”
Appendix 3 shows a comparison of RVUs and exam codes used by the Midland DHBs for
some of the exams specified in the access criteria. Each DHB radiology information system
uses exam codes, and these then map to the RVUs.
It appears that all Midland DHBs use the RANZCR RVUs, but only Taranaki, Lakes and
Tairawhiti use the RANZCR codes (a letter and then 2 numbers), Waikato and BOP do not
(their codes are alphabetical) because they have a new information system (PACS) that
does not currently have the ability to map their codes back to the college codes.
The EAG will have the responsibility of developing a method of comparing standard units of
measurement across the region.
1
The Community Radiology Service Specification (2004) requires purchase unit code CS01001 to be
reported by RVU as specified in the MOH data dictionary
9
3.0 INTRODUCTION
Diagnostic investigation is a necessary, basic component of primary care; yet currently, the
systems within Midland do not consistently support GPs and their patients to access key
diagnostics tests, in particular radiology, where clinically indicated. This lack of consistency
can impact on how long patients wait, referral pathways for accessing these diagnostic tests,
and the level of unnecessary referrals for specialist assessments.
The aims of the Regional Clinical Access Criteria for Primary Referred Radiology SLAT are:
o
to ensure clinically appropriate timeframes for establishing a diagnosis are met
o
reduce avoidable referrals to secondary care services across the Midland Region.
A key factor in achieving these aims is the establishment of a consistent, equitable baseline
for access to all appropriate diagnostic radiology across the region
When making a referral for diagnostic testing primary referrers need to be confident they
can manage and treat the condition likely to be diagnosed. For example: it is unlikely many
GPs have access to immobilising fracture services e.g. plastering. These considerations
should be part of decision-making around whether to refer for diagnostic testing or directly
to ED/specialist services.
A study of GPs using their skills to manage avoidable admissions, showed that only 15% of
the over 700 patients in the study were eventually admitted to hospital (Aish et al 2003). The
authors concluded that, given the resources GPs can successfully manage patients who
traditionally would be sent to hospital.
The SLAT has used the definition of primary referred radiology in the national data
dictionary: “Diagnostic imaging referred by a general practitioner or private specialist.
Excludes tests referred by DHB staff. Excludes maternity ultrasound”
3.1 Background
The Regional Clinical Access Criteria for Primary Referred Radiology SLAT was formed in
late 2010 and developed the criteria attached (Appendix 1). They were developed by the
SLAT with particular assistance from Dr Alina Leigh (Consultant Radiologist) and Dr Paul
Bond (GP). Based on the criteria developed during the Auckland Primary Referred
Radiology Project, they have been ‘Midlandised’ and cross referenced with Health Pathways
(Canterbury) and College guidelines. The draft criteria were presented to ALT on 4 May
2011. It was recommended that a further step be added to the process; that of developing
prioritisation methodology. Simply having access criteria without a way of ensuring those
who are most in need receive imaging first would not address the issue of consistent
practice across the Midland Region.
10
The development of a prioritisation methodology to determine which referrals are given
priority in terms of time to be seen was undertaken over May/June 2011, and was based on
the timeframes outlined in the Primary Referred Imaging Services Referral
Recommendations (1997) with some adjustments (Prioritisation Methodology Appendix 2).
‘When resources are limited urgent examinations (usually hospital inpatients) must take
priority, however any further constraint should fall equally on referrals from primary care and
hospital outpatients, subject always to the clinical radiologist’s decisions on medical priority.’
(Joint statement of Royal College of General Practitioners and Royal College of
Radiologists, 2004).
The SLAT met 6 times2 to 28 June 2011, and had two further teleconferences on 21 & 22
July to ensure all SLAT members had the opportunity to contribute to finalising the Draft
Recommendations Report.
In addition to the Midland SLAT work, a number of initiatives are also underway in NZ to
improve radiology service provision (including primary referred radiology). These include:

Direct ordering of complex imaging by GPs through a software tool (Auckland,
Canterbury, Wellington).

Strategic planning (including primary referred) by regional clinical radiology networks,
(Southern, Mid-Central, Northern regions). These networks are driven though DHB
clinicians. The Midland Region lacks such a network; however work is underway to
develop one.

National workshops to review national radiology guidelines (facilitated by CentralTAS) – these are working on various issues such as standardising relative value unit
(RVU) codes and key performance indicator (KPI) development.
Current primary referred radiology ‘spend’ per DHB is estimated in the graph and table
below and shows the variability in the region:
Relative spend per person on prim ary referred radiology by DHB
May 2011
$35.00
$30.00
$25.00
$20.00
$15.00
$10.00
$5.00
$0.00
Waikato
2
Bay of Plenty
Taranaki
Lakes
Tairawhiti
5 teleconferences and a videoconference
11
Waikato
Bay of Plenty
Taranaki
Lakes
Tairawhiti
Budgeted primary referred radiology expenditure
2011/12
$4,661,924
$3,785,345
$2,751,697
$1,311,698
$1,374,634
Net IDF impact
-23,598.47
51,688.83
46,619.49
-17,743.17
56,897.80
4,638,326.01
3,837,033.87
2,798,316.91
1,293,954.83
1,431,531.80
370,030
$12.53
215,285
$17.82
109,875
$25.47
103,765
$12.47
46,820
$30.58
RVU
$67.94
68,618
RVU
$67.94
55,716
Mix
Internal Block
$67.94
40,502
Population estimate
Estimated expend per person
Purchase methodology (RVU / Block / Other
Price
RVU Volumes (if applicable)
The above information is based on reported rather than purchased activity, and is on total
‘spend’ as not all DHBs contract by RVU activity measures. This activity is also calculated at
total population levels without adjustments for age, deprivation or other demographic factors.
A further graph below identifies primary referred radiology volumes 3 by Midland DHB for the
last 3 years and includes a forecast for 11/12.
Total PRR procedures per 100,000 population
16000
14000
12000
10000
2008/09
8000
2009/10
6000
2010/11
20011/12
forecast
4000
2000
0
Tairawhiti
Waikato
Lakes
Bay of Plenty
Taranaki
The reasons for the differences between DHBs in both graphs vary. Nationally, expenditure
on primary referred diagnostics is higher in smaller units. This finding is believed to be
linked to minimum capacity being required to maintain radiology services, which for small
populations translates into higher access rates.
3
Based on information sent by each DHB to MOH 13 June 2011 – does not include mammography
12
Initial implementation will be within current radiology budgets and will not imply either an
increase in activity or a reduction but rather a more targeted use, which will be monitored to
determine the extent of variation across the region.
4.0 PROBLEM STATEMENT
There has been a growing sense of frustration from primary care around lack of timely
access to imaging to support the care of their patients. Access to primary referred
diagnostic radiology is variable across the Midland Region (and also nationally).
During the SLAT work it became apparent that:
 meaningful, comparative DHB radiology information is limited
 we do not know the potential increase in demand if the proposed waiting times are
met
 the amount and type of work carried out by private radiology services is unable to be
quantified
 DHBs are at different stages of readiness to implement e-referral technology.
An evaluation of a Wellington pilot of primary referred radiology found that Māori and people
living in the most deprived areas had a comparatively low rate of radiology referral. It was
suggested that these aspects require further investigation (Crampton and Bhargava, 2006)
5.0 OBJECTIVES
The objectives for the SLAT are outlined in the Project Initiation Document (PID) (Feb, 2011)
as follows:
To reduce timeframes for establishing a diagnosis and reduce avoidable referrals to
secondary care services by providing consistent access to appropriate diagnostic radiology
across the Midland Region:

Developing clinical access criteria to primary referred radiology that could be applied
to purchasing arrangements across the Midland region

Sustainability - efficient and targeted use of resources and skills to free up capacity
for other front line services
6.0 HOW WILLTHIS CONTRIBUTE TO MHN ACHIEVING CLINICAL TARGETS?
While the outcomes of this SLAT will not directly contribute to the achievement of MHN
clinical targets, the quality of service for key stakeholders will be positively affected:

Potentially improved turn around time from diagnosis/treatment because either the
condition can be diagnosed and treated in primary care, or the patient arrives to see
the specialist with diagnostic radiology tests already carried out.
13

The patient avoids unnecessary specialist appointments made purely to access
diagnostic imaging. This avoids possible cost incurring activities for the patient such
as travel, time off work and child care, and for the health system

No matter where they live in the Midland Region, GPs know what to expect from
publically funded imaging services.

No matter where they are located in the Midland Region, radiology departments
know which referrals should be accepted and the expected timeframes for dealing
with them.
7.0 LINKAGES
This SLAT links to the following:

Better Sooner More Convenient Primary Health Care Strategy

DHB Agreement with the Minister on DHB initiatives to improve access to primary
care

National Radiology Guidelines development (led by CentralTAS)

Midland Region Clinical Services Plan (MRCSP). Radiology has already been
identified as a priority for regional planning, although this is yet to be endorsed by the
appropriate group. There is an IT component of the MRCSP, and therefore any area
identified within the plan will also include an IT focus. It is likely that radiology will
have attention in the 2012/13 planning cycle.

MHN e-referral roll-out plan (when developed)

Midland Region Workforce Development Programme

Midland Region Clinical Radiology Network (when established)
8.0 FUNDING ASSUMPTIONS
As shown in 2.1 and the table below there is wide variation in funding and access across the
Midland Region.
Not all DHBs currently have primary referred access to all items on the criteria list as shown
below:
DHB
Tairawhiti
1. Always
done
X-Ray
CT
US
except for
2. Sometimes
done
3. On list but not
done
CT colonography
Virtual
colonoscopy
CTAs
4. Done but not
on list
Comments

All other CT
(except for column
3)
Sleep tests
All ultrasound
14
DHB
1. Always
done
2. Sometimes
done
column 3
Taranaki
X-rays
CT
US
BOP
X-Rays
CT
US
FL
3. On list but not
done
4. Done but not
on list
Comments
Dental CTs
Cardiac US
Exercise ECGs
Sleep tests etc
Endoscopy
Lung function
tests
Shoulder US
Carotid Doppler
Angiograms
All other CT
Other Ultrasound
not exempted
All X-rays
All FL
Continued use of
exclusion criteria
for US

Waikato
Lakes
X-Rays
US
except for
column 3
X-Rays
US
Fluoroscopy
CT
Muscular/skeletal
US
US biopsies
Tubograms
Proctograms
CT Colonography
CT Scan of Renal
Tracts
CT Head
CT Sinuses
CT recommended
by specialist
Waiting times particularly for ultrasound and CT vary, both within different hospitals in DHB
areas and between DHBs themselves.
There are funding implications for DHBs that are not providing primary referred access for
procedures listed in the criteria and/or that cannot meet the waiting time requirements. This
will relate to resource limitations such as workforce and equipment.
Currently GPs are having difficulty accessing bone density scans, particularly for those
patients requiring these as a prerequisite for publicly funded pharmaceuticals eg Fosamax.
This was discussed during the development of the criteria and the SLAT made the decision
to exclude bone density scans at the present time. If this were to be considered for inclusion
at a later date it would relate to separate agreements, given that bone density scans are not
generally provided through public radiology services.
It is thought that due to capacity or financial disparities between the DHBs the priority
threshold differs. Issues such as population needs, access to the spectrum of imaging
modalities, service sustainability and the impact of private radiology services need
examination
The SLAT has been clear that at this time it is not proposing that these sites reduce activity
to an affordable regional level, or alternatively that larger centres divert funding simply to
match the level of access available at smaller DHBs. The information gathered through
collecting data in more comparable ways may be useful in determining movements towards
15
increased consistency. However, this consistency would need to be weighed against
competing priorities at a DHB level.
Implementation of the access criteria should enable increased clarity for those services that
will be available; those that will not be available, and those routine referrals when the
procedure ‘may’ be available. Eventually it should be possible to split the routine referral
group into sub-sets to give greater clarity and direction as to availability of access across the
region.
In order to identify implementation issues and appropriate data collection, a 6 month review
is recommended (Recommendation 2).
9.0 RECOMMENDATIONS
Recommendations support movement towards more consistent access and prioritisation
criterion for the Midland Region as the diagram below indicates. While there is still some way
to go if DHBs agree to eventually move to a single criterion, the SLAT has made good
progress in agreeing the criteria attached. The aim over time is to move further towards
alignment; however as previously stated that will depend on individual DHB demands and
relative value for money considerations. In some instances, the move to a common set of
criteria will need to be phased in, depending on the readiness of the various DHBs and their
forward commitments, in terms of service planning.
The following diagram shows the progress of the SLAT with the current status outlined in
red.
5 x DHB access and
prioritisation criteria
High level of variation
5 x DHB access and
prioritisation criteria with
some collaboration and
consistency
Single access and
prioritisation criteria for
the region, with local
variation where
required and where
clinically indicated
Single access and
prioritisation criteria for
the region, with out any
local adaptation
16
9.1 Recommendation 1:
Regional access criteria and prioritisation methodology should be implemented
The criteria attached (Appendix 1) are proposed as a minimum level of access to be
implemented across the Midland Region.
The prioritisation methodology (Appendix 2) will apply to all referrals for imaging received
from primary care.
Examples of KPIs and other milestone indicators to clearly measure the impact of
implementation, are identified in Section 11 and will be further developed and finalised by
the implementation Expert Advisory Group (EAG) (see 9.2 below).
Detailed information regarding prevision relating to this proposed minimum will be collected
during initial implementation and reviewed in 6 months.
Currently DHBs will have exceptions or additional pathways that have also been agreed with
primary care eg Waikato DHB CT Urography (CTU) and Bay of Plenty DHB exception list. It
is suggested that DHBs append these exceptions to the access criteria.
9.2 Recommendation 2:
Set up Implementation Expert Advisory Group (EAG) to oversee implementation,
review and rollout
An Implementation EAG should be set up to oversee the detailed planning of implementation
of the access criteria/prioritisation methodology and the 6 month review, and rollout of the
electronic referrals. It is recommended that this group include analyst, IS and radiology
administration resource.
The EAG will be responsible for working with each DHB in turn as the process is rolled out in
the region. An important link will be with the Midland CIOs.
During implementation the EAG will ensure consistency of approach between DHBs and
between GP practices.
It is recommended that the EAG have a timeframe long enough to allow for oversight of
initial implementation, the review, and then the adjusted implementation/rollout. An important
feature of this work will be the standardising of practice across the region and a decision will
need to be made by DHBs as to which unit of measure will be used.
The EAG’s tasks will be to:

Develop a project plan for implementation
17

Develop data dictionary and collection systems and processes; and ensure baselines
are in place before implementation.

Plan comprehensive communications and any training required

Review the data monthly to identify issues as implementation progresses and to
understand monthly variation
Agreement to resourcing the implementation and active involvement of DHBs and the MHN
will be essential, as will the agreement from other PHOs to participate in the use of
electronic referrals.
The following phasing is suggested:

Phase 1: Pre-implementation: This phase will be the most important and will consist
of setting up the structures and processes to ensure implementation is well-planned
and that the 6 month review measures are consistent and meaningful, and that
baselines are able to be collected. Because implementation will include PHOs/GPs
other than those affiliated to MHN, comprehensive communications will need to be
developed. In addition, this phase will also include developing a generic radiology
referral form.

Phase 2: Implementation of the access criteria and prioritisation methodology across
the district using e-referrals (staging dependant upon DHB readiness).

Phase 3: Reviewing the data at 6 months following implementation to identify issues
relating to e-referrals and provision of primary referred diagnostic radiology according
to the access criteria and prioritisation methodology4.

Phase 4: Adjustments identified that are needed to the process/data in participating
DHBs prior to further roll out.

Phase 5: Rollout to any remaining DHBs/PHOs. This phase should also eventually
include embedded criteria/prioritisation methodology. The timeline should align with
the MHN e-referral roll out plan and MRCSP.
9.3 Recommendation 3:
Implementation should be within current radiology budgets
Because it is unknown what if any funding implications will arise for DHBs through the
application of access criteria/prioritisation methodology, it is recommended that DHBs work
within their current radiology funding and prioritise their referrals according to the
methodology (Appendix 2). This will be achieved through adjusting the number of routine
tests done each month. It should be possible for a DHB to determine on a monthly basis how
much resource is left after providing urgent and semi-urgent imaging that can be spent on
routine imaging.
4
Ethnicity and domicile data will be included in the review
18
A greater understanding of the issues of applying the criteria will be gained from the 6 month
review, along with clarity around volumes (as long as a standard measure can be agreed).
Budget-holding by primary care was discussed. It was thought that this may be a mechanism
to improve referral appropriateness and responsiveness. However it was not progressed by
the SLAT. It may however be an option for consideration as part of Midlands Health Network
locality planning.
9.4 Recommendation 4:
Implementation of access criteria/prioritisation methodology should include
electronic referrals
9.4.1
Electronic referrals
Referrals are the mechanism by which health practitioners request care from; or transfer
responsibility for patient care to other practitioners on behalf of a patient. Currently the
majority of referrals are paper-based and sent as letters or faxes, however; referrals are
increasingly being sent securely (encrypted) through the internet.
9.4.2
Implementation in the Midland Region
GPs who use MedTech32 as their PMS (Practice Management System) will refer to
Radiology departments directly from their PMS on a generic radiology referral form.
The EAG will work with those DHBs where the ‘catching’ system within the DHB/Radiology
departments is not yet capable of receiving electronic referrals to determine interim referral
management processes. The EAG will also ensure planning links with the Midland CIOs.
Electronic referrals are based on BPAC’s (Best Practice Advocacy Centre) BestPractice
clinical decision support platform. The electronic referral solution is made available to GP
practices that use MedTech32 as their PMS.
The solution uses a generic template (one size fits all) which integrates with MedTech32 and
is submitted across the internet to BPAC (Best Practice Advocacy Centre) in Dunedin.
Referral processing staff logon to the BPAC Referral Receipt client to print their services’
referrals.
A generic radiology referral template is proposed. In the interim this may not exactly suit all
radiology needs, however the referral would be readable and would be administratively
complete. Use of the generic radiology referral template ensures that all required information
is included on the referral, and this is so much easier as most of the required information is
automatically completed. The system is in place currently for most specialties at Waikato
DHB and GPs report less clarifying phone calls from Waikato DHB seeking additional
information which they had ‘forgotten’ to include on the referral.
19
Once referrals are generated electronically radiology services could access the Referral
Client application via the internet to print referrals for their service if required. This can be
easily achieved with a small amount of training and requires no set up costs or special
applications. It can be carried out from a current computer.
While initially this does not allow embedding the criteria in the referral form, an option to at
least provide access to the criteria via an electronic link in the form, is being actively pursued
at present.
The drop down box (where the GP chooses the specialty to refer to) should also include a
‘public/private’ option. This would assist with quantifying the referrals to private radiology
services.
Comprehensive communications will be planned as part of this initiative.
9.4.3
Alignment with regional planning
Rollout to those DHBs whose capability needs enhancing could be aligned with regional IT
planning and it may be possible to fully embed the criteria and prioritisation methodology into
the referral form by the time the 6 month initial implementation has been completed and
reviewed.
It appears that DHB regional planning processes are likely to make radiology a priority in the
next year5.
It is recommended that the following should be incorporated into DHB and regional planning
processes:

The Midland Clinical Services Implementation Plan (MRCSP) states that electronic
referrals and discharges will be implemented across the region by June 2012.6 This
needs to include radiology.

That the capability be built for radiology departments to allow booking details to be
seen by the primary referrer in real time.

That the capability be built for primary care to view imaging results in an appropriate
timeframe.

That the access criteria and prioritisation methodology should be embedded in the
electronic referral documentation i.e, referral form (The SLAT has advised that
without this capability, use of the criteria and methodology within primary care will not
be maximised).
In addition it is timely to align this proposal with the e-referral strategy and timeline led by
MHN.
5
Email from Ian Goulton Programme Manager Midland Regional Clinical Services Plan (9 June
2011)
6
P22 – part of the Midland Region IS Plan
20
To ensure the learning from the review is incorporated into the next phase of implementation
the EAG overseeing initial implementation should also be responsible for planning and
rolling out adjusted implementation.
9.5 Recommendation 5:
Ability for primary care to directly refer for planned/staged/follow up imaging
should be explored as part of implementation
If GPs can refer for diagnostic imaging and manage many of the conditions diagnosed within
primary care, it would be useful for them to be able to also refer for staged, planned or follow
up imaging. For example, a GP may receive a specialist radiologist report indicating a follow
up X-ray within in a specific timeframe. It is believed that if the GP were able to organise the
follow up imaging and subsequent care it would reduce the number of secondary service
outpatient reviews.
While follow up access to imaging was not in the scope of the current SLAT work, it has
been raised as something that should be explored as part of implementation.
10.0 OUTCOMES / MEASURES
The desired outcomes of implementing consistent regional access criteria and prioritisation
methodology (see Section 4) are to:

Manage service demand within clinically appropriate timeframes for establishing a
diagnosis and reduce avoidable referrals to secondary care services

Develop clinical access criteria to primary referred radiology that could be applied to
purchasing arrangements across the Midland region

Increase sustainability - efficient and targeted use of resources and skills to free up
capacity for other front line services
Implementation of the criteria will rely on the collection of consistent information in order to
determine if these outcomes are able to be influenced by the introduction of standard access
criteria and prioritisation methodology.
11.0 KEY PERFORMANCE INDICATORS
In radiology there are some aspects of work which should be readily measurable. These
may measure individual components or the entire system.
The following information should be collected monthly by DHBs over a 6 month period
following implementation. The information will be used to clarify understanding of regional
variation.
21
DHB
Number & %
Urgent
where
imaging
occurs
within 7
working
days
Number & %
Semi urgent
where
imaging
occurs
within 1
month
Number & %
Routine
where
imaging
occurs within
2 months
Number & %
Declined
Number & %
Declined
(Meets criteria
but can’t do
within 6
months)
(doesn’t meet
criteria)
Waikato
Bay
of
Plenty
Taranaki
Tairawhiti
Lakes
The implementation EAG will work with the DHBs to develop a standard set of indicators for
measuring the impact of criteria application. This should be a ‘whole of system’ approach
whereby the impact is measured not only on primary referred radiology but on all radiology
referrals.
In addition the electronic referral process will provide valuable information regarding primary
care referral patterns. It may also be possible to quantify the amount of referral to private
providers that is occurring.
The development of indicators will be a vital part of the EAG’s work. The SLAT had a lot of
discussion about what should be measured in order to understand the impact of applying the
criteria (for example how FSAs should be monitored to identify any reduction), however no
agreement was reached.
22
12.0 RISKS
12.1 Risks (if recommendations are implemented)
Risk #
Risk Area
Description/likelihood
Mitigation Strategy
1
Equity of Access
Inequities of access continue despite
the implementation of standard
criteria
Variations better
understood through
review – mitigations to
be planned based on
information gathered
2
Media
There may be a perception risk if
transparency highlights varied access
Determine impact of
implementation
through review
3
Cost shifting
Risk of private work (currently
privately or insurance funded) moving
to public funding if access becomes
more explicit. Balance between public
and private changed with no health
gain
Unable to mitigate at
this time. Size of the
issue unknown. May
be able to be
measured via
electronic referral
process
5
Capacity
More or new tests putting pressure on
resources (equipment & clinicians )
Determine impact of
implementation
through review
6
Budget
DHBs may not be able to meet
timeframes and may exceed budget
Manage current budget
within prioritisation
methodology – 6
month review
7.
Implementation
failure
Review does not produce useable
results. Non-compliance of
DHBs/GPs. GPs aren’t aware of
access criteria
Agreement by key
stakeholders to
undertake and
adequately resource
implementation/review.
Careful planning and
implementation of
measures.
Comprehensive
communications plan
23
12.2 Risks (if recommendations are not implemented)
Risk
#
Risk Area
Description/likelihood
Mitigation
Strategy
1
Equity of Access
No change to systems and processes.
Patients get diagnostic tests depending
on where they live. Duplication of
radiology tests in public and private.
Māori & lower socio-economic areas
disadvantaged . No FSAs avoided.
May be mitigated
by MRCSP
2012/13
2
System
Other primary care service/patient
pathway improvements not supported
by consistent access to diagnostics
May be mitigated
by MRCSP
2012/13
3.
Quality
Time to diagnosis delayed by need to
attend FSAs.
May be mitigated
by MRCSP
2012/13
4
Data/Information
Midland region remains unable to
meaningfully compare primary referred
imaging information.
May be mitigated
by eventual
national
requirement to
move to
consistent RVUs
5
Budget
No savings made through avoidable
FSAs
May be mitigated
by MRCSP
2012/13
6
Political
Opportunity to create regional
consistency regarding primary referred
radiology delayed or lost
Clinical Network
may mitigate
when formed
7
Information/communication
GPs continue to be unclear whether
their referrals will be accepted and the
timeframes they should expect referrals
to be actioned within
Clinical Network
may mitigate
when formed
13.0
IMPLEMENTATION PLAN AND TIMEFRAMES
The following plan outlines the indicative timeframes and resources to achieve
implementation.
Implementation involves three related but different processes:
1.
Electronic referrals and associated system/process changes
2.
Access to and commencing use of the access criteria and prioritisation
methodology
3.
Information collection and monitoring
24
1.
Electronic referrals
Regional implementation of the e-referral process is a sub-section of the Midland Region
Information Services Plan, and primary referred radiology e-referrals will be managed under
their auspices (led by MHN). The timeline for regional implementation of e-referrals is
currently under development (but the rollout is expected to be completed within 12 months of
commencement).
The following shows the envisaged project linkages:
PHOs
GPs
Midland DHB
P&F GMs
ALT
Midland ISSP
Radiology EAG
E-referral in GPs
(with criteria
accessed
electronically) +
DHBs.
Both sending +
catching
processes
Criteria +
Prioritisation
methodology in
use by DHB
radiology
departments for
accepting/
prioritising
referrals
Clinical Advisory
Group
DHBs
2. Access criteria and prioritisation methodology
This will be managed by the EAG with strong linkages to the e-referral implementation.
As soon as the recommendations are signed off by the DHBs and the data and
monitoring requirements are agreed, Radiology Departments can begin using the
prioritisation methodology/access criteria.
GPs will be able to use the access criteria as soon as the electronic form is available.
However hard copies of the access criteria will be sent to PHOs for information and
distribution when the timeline for e-referral implementation for their DHB is clear.
3. Information collection and monitoring
This will be led by the EAG and standardised processes and collection agreed by DHBs.
They will need to be in place before the prioritisation methodology is implemented so that
measuring can begin at the same time.
25
Because the e-referral action plan and timeline will be determined by the MHN (Midland
ISSP) e-referral business case which at time of writing is still under development, there has
been no attempt to allocate e-referral time frames or resources to this plan (other than the
best guesses that appear below). Midland ISSP likely involvement is indicated by the pink
shaded boxes.
What
Responsibility
Delivery
Date
Estimated Resource
22 Sept
Regional Project manager
PHASE 1 – Pre-implementation
Consultation phase
CGG
Planning & Funding
GMs
5 hours
COOs
Agreement of DHBs & MHN
to participate in and
resource as per the plan
Planning & Funding
GMs & MHN CEO
Oct 11
Regional Project manager
Other PHOs agreement to
participate in use of
electronic referrals
CEOs
Oct 11
MHN (Midland ISSP)
TBC
Identify DHBs/PHOs order
of participation
MHN (Midland ISSP)
Oct 11
Regional Project manager
TBC
5 hours
Key stakeholder
communications
Implementation EAG
Nov 11
MHN (Midland ISSP)
TBC
Network General Practice Manager 10
hours
5 hours
Regional Planning & Funding GMs
Regional Project manager 10 hours
Identify EAG members, set
up EAG and supporting
structure
DHBs/ALT
Nov 11
Regional Project manager
Develop implementation
TOR
Implementation EAG
Develop & implement
Generic Radiology referral
form
MHN (Midland ISSP)
Nov11
Network General Practice Manager
MHN, BPAC &
Radiology
TBC
24 hours
10 hours
Nov11
Regional Project manager
16 hours
Regional Project manager 10 hours
Local Radiology manager/radiologist
5 hours
BPAC 24 hours
Develop project plan &
communication plan
Implementation EAG
Nov 11
Regional Project manager 24 hours
MHN (Midland ISSP)
TBC
Network General Practice Manager 24
hours
MHN IS 5 hours
Map current radiology work
processes
Participating DHBs
Nov 11
Regional Project manager 10 hours
MHN (Midland ISSP)
TBC
Local Radiology managers & booking
26
What
Responsibility
Delivery
Date
Estimated Resource
clerks 8 hours
Local DHB IS 2 hours
Indicators finalised and
standardised. Baselines
sourced. Data dictionary
developed
Implementation EAG &
analysts
Dec 11
Regional Project manager 40 hours
Regional P&F Analyst 40 hours
Local DHB provider arm analysts 20 hours
MHN analyst 10 hours
Set up reporting
methodology/template and
validation of reports
Implementation EAG &
analysts
Agree 6 month review
methodology/template
Implementation EAG &
analysts
Dec 11
Regional Project manager 10 hours
Regional DHB P&F analyst 8 hours
MHN analyst 8 hours
Dec 11
Regional Project manager 4 hours
Local DHB provider arm analysts 4 hours
MHN analyst 4 hours
Develop implementation
support pack for GPs
Implementation EAG
Dec 11
MHN (Midland ISSP)
DHBs?
Network General Practice Manager 20
hours
MHN trainer 20 hours
Regional Project manager 10 hours
PHASE 2 – Implementation across the Midland Region
Implementation of criteria
and prioritisation
methodology in all DHBs &
PHOs
DHB & MHN/PHOs
Dec 11
Local DHB radiology manager/CD 40
hours
Network General Practice Manager 10
hours
Other PHOs 10 hours each
E-referral training
Implementation of ereferrals at identified DHBs
MHN (Midland ISSP)
Dec 11
MHN trainer 56 hours
MHN, DHB, other PHOs
TBC
Local DHB IS 10 hours
MHN (Midland ISSP)
Dec 11
DHBs, MHN & other
PHOs
TBC
Network General Practice Manager 160
hours
Local DHB radiology booking clerks 20
hours, managers 20 hours, radiologists 8
hours
Local DHB IS 120 hours
Other PHOs 24 hours each
Regional Project manager 10 hours
Monthly reporting
DHB & MHN/PHOs
Monthly
Local DHB provider arm analysts/radiology
manager 4 hours per month
MHN analyst 4 hours per month
Monthly identification of
volumes/implementation
issues
DHB & MHN/PHOs &
Implementation EAG
Monthly
Local DHB provider arm analysts/radiology
manager 4 hours per month
MHN analyst 4 hours per month
27
What
Responsibility
Delivery
Date
General co-ordination
Estimated Resource
Regional Project manager 20 hours
PHASE 3 –review at 6 months
Amalgamation of data
DHB & analysts
July 12
Regional Project manager 4 hours
Regional DHB P&F analyst 20 hours
Local DHB provider arm analysts 8 hours
Local radiology manager 4 hours
Review of data against
indicators
Implementation EAG
July 12
Regional Project manager 10 hours
Regional DHB P&F analyst 10 hours
Local DHB provider arm analysts 4 hours
MHN analyst 4 hours
Network General Practice Manager 4
hours
Consult with CGG
Consult with DHBs
Report findings and
recommendations to ALT &
CGG
Implementation EAG
July 12
Regional Project manager 8 hours
Implementation EAG
July 12
Regional Project manager 10 hours
Implementation EAG
Aug
2012
Regional Project manager 30 hours
PHASE 4 – Adjustment and roll out to any other DHBs/PHOs
Adjustments implemented
in participating DHBs
MHN (Midland ISSP)
Implementation EAG
Sept
2012
TBC
Adjusted implementation
with e-referrals extended to
any DHBs/PHOs still to
participate
MHN (Midland ISSP)
Implementation EAG
Regional Project manager 10 hours
Local DHB provider arm Radiology
managers 20 hours
Sept
2012
Regional Project manager as per Ph 2
TBC
Network General Practice Manager as per
Ph 2
TBC
Network General Practice Manager
DHB radiology manager/CD as per Ph 2
PHASE 4a – Improvements
Specific radiology referral
form developed
MHN (Midland ISSP)
Project manager
Radiology manager/radiologist
Criteria embedded in
referral form
MHN (Midland ISSP)
TBC
MHN/BPAC
Network General Practice Manager
28
14.0
SUMMARY OF ESTIMATED RESOURCES AND GANTT CHART
7
Summary of estimated resource requirements per role across project phases:
Individual DHBs (ea)
EAG
Regional Project
MHN
Other individual PHOs (ea)
Total
$10,400.84
$22,781.10
$16,826.46
$22,032.60
$920.43
$72,961.43
There is also potentially a small increase in operational costs for DHBs associated with the implementation of a new referral pathway - the
referral acknowledgement transaction. MHN is concluding a commercial arrangement with BPAC covering this topic.
The above costs do not include those under the Regional E-referral Plan which will come under the Midland Region ISSP.
1.
Local (per DHB)
Organisation
Per local Midland DHB
participating in
implementation
7
Role
Phase 1
Preimplementation
Sept – Nov 2011
Phase 2
Implementation to X
DHBs/PHOs
Nov - Dec 2011
Phase 3
Review at 6 months
June 2012
Total Sept 2011 to
July 2012
(hours)
Phase 4
Adjustment/Rollout
to X DHBs/PHOs
Aug - Nov 2012
Provider arm analyst
24
48
12
84
48
Radiology manager
8
60
4
72
60
Radiologist/CD
4
8
12
8
Dollars based on fully absorbed salary costs
29
Organisation
Role
Radiology booking
clerk
Phase 1
Preimplementation
Sept – Nov 2011
Phase 2
Implementation to X
DHBs/PHOs
Nov - Dec 2011
Phase 3
Review at 6 months
June 2012
Total Sept 2011 to
July 2012
(hours)
Phase 4
Adjustment/Rollout
to X DHBs/PHOs
Aug - Nov 2012
8
20
28
20
2
10
12
10
Provider arm sub-total
46
146
16
208
146
Provider arm estimated
cost
$2,232.00
$7,386.48
$782.36
$10,400.84
$7,386.48
Phase 3
Review at 6 months
June 2012
Total Sept 2011 to
July 2012
(hours)
Phase 4
Adjustment/Rollout
to X DHBs/PHOs
Aug - Nov 2012
IS support
2.
Regional (across DHBs/PHOs)
Organisation
Expert Advisory Group
EAG estimated cost
Role
Governance/expert
advice
Phase 1
Preimplementation
Sept – Nov 2011
Phase 2
Implementation to X
DHBs/PHOs
Nov - Dec 2011
18
30
18
66
18
$6,212.85
$10,355.40
$6,212.85
$22,781.10
$6,212.85
30
Organisation
Project DHB
Role
Phase 1
Preimplementation
Sept – Nov 2011
Project manager
159
P&F analyst
40
Phase 2
Implementation to X
DHBs/PHOs
Nov - Dec 2011
34
Phase 3
Review at 6 months
June 2012
Total Sept 2011 to
July 2012
(hours)
Phase 4
Adjustment/Rollout
to X DHBs/PHOs
Aug - Nov 2012
62
255
20
30
70
Project DHB sub-total
199
34
92
325
20
Project DHB estimated
cost
$10,302.97
$1,760.31
$4,763.18
$16,826.46
$1,035.47
As per E-referral
plan
As per E-referral plan
As per E-referral
plan
As per E-referral
plan
78
170
252
20
Midlands Health Network
MHN (Midland ISSP) Ereferral implementation
Network General
Practice Manager
BPAC
GP Trainer
Analyst
4
24
24
20
56
10
48
8
76
20
66
5
31
Organisation
Role
IS support
Phase 1
Preimplementation
Sept – Nov 2011
Phase 2
Implementation to X
DHBs/PHOs
Nov - Dec 2011
Phase 3
Review at 6 months
June 2012
Total Sept 2011 to
July 2012
(hours)
Phase 4
Adjustment/Rollout
to X DHBs/PHOs
Aug - Nov 2012
15
5
5
10
MHN sub-total
137
284
12
433
50
MHN estimated cost
$7,087.25
$14,324.07
$621.28
$22,032.60
$2,444.87
5
10
5
20
$230.11
$460.21
$230.11
$920.43
Per non-MHN PHOs
participating in
implementation
PHO estimated cost
Planning,
communication &
review
32
33
15.0
o
REFERENCES & BIBLIOGRAPHY
Aish H, Didsbury P, Cressey P, Grigor J, Gribben B. Primary Options for Acute Care: general
practitioners using their skills to manage ‘avoidable admission’ patients in the community. New
Zealand Medical Journal, Vol 116 No1169. 21 February 2003
o
Auckland Triage Criteria for Access to Diagnostics, V1. Auckland Primary referred Radiology
Project, 2011
o
Better Sooner More Convenient Health Care in the Community, Ministry of Health Information
Booklet, 2011
o
Canterbury DHB, Partnership Health Canterbury, Christchurch PHO, Rural Canterbury PHO.
Canterbury Health Pathways, 2010 www.healthpathways.org.nz
o
Capital & Coast DHB Gastroenterology Clinical Pathways, Capital & Coast DHB Gastroenterology
Clinical Pathways Collaborative Working Group, August 2010
o
Capital & Coast CT Colonoscopy, Guidance for referrals from primary care, Gastroenterology
Clinical Pathways Collaborative Working Group, August 2010
o
Central Region Radiology Standards and Key Performance Indicators January 2011 Central
Regional Standards and Key Performance Indicators, Central Region District Health Boards Prepared by: Central Region Radiology Key Performance Indicators working group on behalf of
the Regional Radiology Group
o
Crampton P, Bhargava A. The Community Referred Radiology Scheme: an evaluation. New
Zealand Medical Journal, Vol 119 No1236. 23 June 2006.
o
Government
of
Western
Australia
Diagnostic
Imaging
Pathways,
September
2010
http://www.imagingpathways.health.wa.gov.au/includes/index.html
o
International Radiology Quality Network (IRQN) 2010 http://www.irqn.org/
o
Joint Statement of Royal College of General Practitioners and Royal College of Radiologists 2004
http://www.rcgp.org.uk
o
Midlands Health Network Strategic Plan 2011-2014
o
Ministry of Health Community Radiology Service Specification, 2004
34
o
Northern Region, Radiology Strategic Plan: Phase 2 Long Term Health Services Plan. March
2010
o
Primary Referred Imaging Services Referral Recommendations, Midland Regional Health
Authority December, 1997
o
Radiology National Referral Guidelines, V1 Radiology Referral Guidelines and Prioritisation
Criteria Health Funding Authority September 2001
o
Royal College of Radiologists Referral Guidelines Working Party. Making the best use of clinical
radiology services, Referral Guidelines. (MBUR6) 2007 http://mbur6.nhs.uk/
o
Taranaki DHB, Radiology Standing Orders
35
Appendix 1
MIDLAND REGION ACCESS CRITERIA FOR PRIMARY REFERRED RADIOLOGY
JUNE 2011
PREAMBLE
8
The following regional access criteria for primary referred radiology referrals have been developed
from a number of sources, principally the Auckland DHB Access to Diagnostic Project (2010) and the
West Australian Radiology Referral Guidelines (2010)
If your patient does not meet the criteria but you think that an investigation is warranted, please phone
a DHB consultant for advice (see page 11). If they advise an investigation please document their
name as well as all clinical information on the request form.
These criteria have been developed to improve equity of access across the Midland Region. They are
a minimum that should be provided and should be read in conjunction with the Prioritisation Criteria
developed by the Midland Region Access Criteria for Primary Referred Radiology Service Level
Alliance Team (June 2011).
XRAY

CHEST XRAY
Either of the below to qualify
 The results of a CXR, either positive or negative, will alter the management of this patient’s
condition.
 The results of this CXR will either confirm or eliminate significant disease from the differential
diagnosis.

SHOULDER XRAY
Two of the below needed to qualify
The pain has been present for >4 weeks.
 There are signs of bursitis or tendonitis.
 The pain was sudden in onset and is severe and <4 weeks duration.
 There is swelling near the joint.
 There is a palpable mass or deformity.
 There is limited ROM (range of movement).
8
developed by the Regional Access Criteria for Primary Referred Radiology Service Level
Alliance Team (SLAT)
36

KNEE XRAY
Two of the below needed to qualify
 Patient has anterior patella-femoral knee pain (this will request axial views in addition to the usual
AP and lateral views)
 The pain has been present for >4 weeks.
 The pain was sudden in onset and is severe and <4 weeks duration.
 There is swelling near the joint.
 There is a palpable mass or deformity.
 There is limited ROM (range of movement).
 There is evidence of inflammatory arthritis.
BMI (value) and Height and Weight needed on referral form.

WRIST AND HAND XRAY
Please note that x-rays are not indicated for short duration pain or tenderness over a specific tendon.
One of the below needed to qualify.
 Pain has been present for >4 weeks and no response to treatment and/or progressive symptoms.
 Unrelenting severe pain <4 weeks.
 Significant restriction in activity or ROM (range of movement) after 4 weeks.
 Pain present but not reproduced on assessment (e.g. Keinbock’s Disease).
 Unexplained deformity/palpable enlarging mass or swelling.
 Joint instability
 There is evidence of inflammatory arthritis.

ELBOW XRAY
One of the below needed to qualify
 Pain has been present for >4 weeks and no response to treatment and/or not reproduced on
examination.
 Unrelenting severe pain <4 weeks.
 Significant restriction in ROM (range of movement) after 4 weeks.
 Unexplained deformity/palpable enlarging mass or swelling.
37
 There is evidence of inflammatory arthritis.

HIP XRAY
One of the below needed to qualify
 Chronic hip pain >4 weeks.
 Chronic hip stiffness >4 weeks.
 Inability to weight bear because of hip pain.
 Previous total joint replacement with current symptoms
Please note it is often useful to x-ray the pelvis at the same time

ANKLE XRAY
Two of the below needed to qualify.
 The pain has been present for >4 weeks.
 The pain was sudden in onset and is severe and <4 weeks duration.
 There is swelling near the joint.
 There is a palpable mass or deformity.
 There is limited ROM (range of movement).
 There is evidence of inflammatory arthritis.

SPINE XRAY
 Cervical
 Thoracic
 Lumbar
Two of the below needed to qualify
 Spine pain >6 weeks.
 Spine pain and osteoporosis or prolonged use of corticosteroids.
 Spine pain and suspicion (or history) of cancer (unexplained weight loss etc).
 Spine pain and immunosuppression.
 Spine pain and signs of infection (raised CRP, WBC, unexplained fever etc).
 Focal neurologic deficit with disabling symptoms.

ABDOMEN XRAY
 Suspected renal tract stone (for acute renal colic please use POAC)
38
ULTRASOUND

ABDOMEN ULTRASOUND
One of the following needed to qualify
 Abnormal Liver Function Test (LFTS) or suspected fatty liver (any two of GGT/AST/ALT
significantly elevated for >3months with no other clinical cause).
 Abnormal LFTS – acute elevation with suspected biliary tract obstruction or malignancy (infective
causes and medications excluded).
 Abdominal mass or other palpable abdominal abnormality.
 Painless jaundice without obvious cause.
 Clinical biliary colic/gallstones (not already imaged).
 Persistent right upper quadrant pain.
 Suspected aortic aneurysm (AAA) Radiological report indicates the following maximum
measurement of aorta:
 Normal < 3 cms
No further routine radiology FU
 AAA 3 – 3.9 cms
Repeat scan 2 years
 AAA 4 – 4.5 cms
1 year scan
 AAA 4.6 – 5.0 cms
6 month scan
 AAA 5.1 – 5.5 cms
3 month scan
 AAA 5.5 – Over
URGENT vascular referral
 If expansion
URGENT vascular referral
> 7mm in 6 months
> 1 cms in 12 months
(CT Scan is a more sensitive investigation for suspected pancreatic disease. Please discuss with a
DHB Consultant.)

RENAL ULTRASOUND
One or more of the following for all urological tests:
39
 Proteinuria > 0.5gm/24 hours or protein/creatinine ratio > 50mg/mmol.
 Albuminuria – albumin/creatinine ratio > 33 mg/mmol (in diabetic patients with known diabetic
complications an ultrasound may not be indicated. Please discuss with DHB Consultant.
 eGFR consistently below the lower limit for age (see chart below). Please repeat with well hydrated
patient. If abnormal refer for renal US
180
160
60
50
140
120
40
100
80
30
60
40
20
Low Limit
Median
High Limit
60 mL/min
%<60 mL/min
10
20
0
90-99
80-89
70-79
60-69
50-59
40-49
30-39
0
16-29
eGFR (mL/min/1.73m2)
eGFR Chart
Age (years)
Haematuria
 Haematuria in younger patients < 40 years
 Persistent isolated microscopic haematuria (on two or more MSU; not dipstix) or acroscopic
haematuria
 Polycystic kidneys - Family history (one or more first degree relative) then ultrasound patient when
>20 years age. Serial ultrasounds are not indicated unless other clinical factors.
UTI
Females:

Persistent or recurrent UTI > 4 per year with failed medical management including
prophylaxis. (Ensure that patient has not previously been investigated with imaging)

Pyelonephritis single episode.
Males:

Recurrent or persistent infections (if not previously investigated with imaging)

Loin pain suggesting PUJ renal tract obstruction.

Chronic urinary retention with palpably enlarged bladder.

Suspected prostatomegaly
40
(Ultrasound of the prostate alone (without biopsy) is not a useful investigation. Please refer to Urology
for Ultrasound Guided Prostate Biopsy.)

SCROTAL ULTRASOUND
One or more of the following
 Scrotal masses (for urgent referral for testicular masses (ie within 48 hours) – discuss with
radiologist)
 For suspected hernia
 For trauma
 For scrotal pain
Note: for suspected torsion immediate referral to ED

SHOULDER ULTRASOUND
Two of the following:
 Subacute shoulder pain
 Suspected rotator cuff tear or impingement. (Plain x-rays having been done)
 Coracoacromial arch deformity detected

PELVIC ULTRASOUND
One or more of the following
 IUCD not visible on examination
 Abnormal pre-menopausal bleeding:
Please also select one of the following:
 >45 years
Or
 >35 years
In addition your patient must meet at least one of the following:
 Weight > 90kg
 History of tamoxifen use or unopposed oestrogen
41
 Nulliparous
 Chronic anovulation +- infertility
 Family history of carcinoma uterus
And the general practitioner should have completed ALL of the following:
 I have visualized the cervix and taken a Chlamydia swab, and a smear
 I have removed an IUCD and observed for 3 months, or there is no IUCD present
 I have carried out a pelvic examination, visualized the cervix and taken a smear
and:
 There has been no improvement with a three month trial of medical management
(hormonal/tranexamic acid/mirena)
 Primary amenorrhoea (delay of menarche after age 18)
 Pelvic mass on examination (request urgent scan)
 Post menopausal bleeding after 1 year of amenorrhoea
 Polycystic Ovary Syndrome (PCOS) – see below for PCOS:
Because of their limited contribution to the diagnosis and management of PCOS, ultrasound
scans are low priority. Diagnosis of PCOS is made by the presence of 2 out of the 3 following
criteria:
1.
Oligomenorrhoea or amenorrhoea
2.
Clinical and/or biochemical signs of hyperandrogenism
3.
Polycystic ovaries
If criteria 1 and 2 above are met (and other causes have been excluded), the diagnosis
is made and an ultrasound is not required
Clinical suspicion of PCOS and:

Oligomenorrhoea or amenorrhoea. Clinical examination and laboratory investigations
have excluded causes other than PCOS
Or

Clinical and/or biochemical evidence of hyperandrogenism. (Clinical examination and
laboratory investigations have excluded causes other than PCOS)

CAROTID DOPPLER
 Fully resolved TIA or minor stroke not requiring hospital admission
 Carotid territory clinical features
42
 Patient is a potential candidate for surgical endarterectomy if stenosis confirmed
Please note that some patients may need acute hospital referral even if symptoms have resolved
The following syndromes and symptoms will NOT generally qualify the primary care patient for a
carotid ultrasound: isolated dizziness; headache; confusion; pure hemianopia; ataxia; diplopia.
Asymptomatic carotid bruits will NOT qualify for a carotid ultrasound.
Use this table to assess your patient’s ABCD2 score. Most patients with a ABCD2 score > or = 4
should be admitted to hospital even if the deficit has fully resolved, unless the event was > 2 weeks
ago. Please discuss with DHB Neurologist if needed.
ABCD2 Score
A
Age
>/= 60
1 point
B
Blood Pressure
> /= 140/90
1 point
C
Clinical
D
E
Duration
i.
Unilateral weakness
2 points
ii.
Speech impairment
without weakness
1 point
1 – 59 mins
1 point
> or = 60 mins
2 points
Diabetes

1 point
THYROID ULTRASOUND
One of the following only:
 Neck masses
 Thyroid nodule
 Unstable multinodular goitre
 If not associated with dysphagia, respiratory embarrassment or rapidly enlarging mass
COMPUTED TOMOGRAPHY (CT)
43

CT SCAN SINUS
Anosmia
 With associated nasal symptoms not responsive to medical management.
Chronic Sinusitis
 > 3months duration
And
symptoms including at least two of the following:
 Nasal congestion/obstruction.
 Purulent secretions.
 Facial pain/pressure.
And
at least the first two of the following:
 Inadequate response to 4 weeks of antibiotic therapy and
 Oral prednisone 20mg per day for minimum 1 week (unless contraindicated) and
 Oral antihistamines if associated with allergy
 6 wks of intranasal steroids if associated with allergy.
Recurrent sinusitis
One of the following:
 At least 3 separate episodes within a 1year period.
 >3 months of symptoms in a year.
And
both of the following:
 Symptoms including nasal congestion/obstruction, purulent secretions and facial pain/ pressure.
 Inadequate response in each episode to antibiotic therapy, oral prednisone 20mg per day for 1
week and oral antihistamines if associated with allergy
Chronic unilateral nasal obstruction
Both of the following:
 Non responsive to medical treatment.
 Not caused by deviated nasal septum
44
And
at least one of the following:
 Epistaxis.
 Associated pain / headache.
 Associated with foul smell.

CT COLONOGRAPHY
At least two of the following
 Change in bowel habit
 Abdominal pain
 Weight loss
 Constipation
 Iron deficiency anaemia
 Does not have ‘blood in stools’
 For elderly, where exclusion of malignancy is the clinical question and where colonoscopy is high
risk or is technically difficult
 For incomplete colonoscopy
 For those where colonoscopy or sedation for colonoscopy contraindicated
 Where colonoscopy previously very difficult
If you are unsure please discuss with your radiologist

CT SCAN of RENAL TRACTS
o
Renal Colic for Non-Contrast CT Scan
One or more of the following
 If no history of renal colic
 If not pregnant
 In older patients with atypical symptoms
 If calculus seen on AXR
 If hydronephrosis on US
For younger patients (40 years and under):
 AXR and US Is first line investigation
45
If you are unsure please discuss with your radiologist
o
Painless Microscopic Haematuria
One or more of the following
 If negative culture
 If 3 positive MSU for haematuria and absence of RBC casts
 With normal renal function
 If >40 years
 If risk factors
If you are unsure please discuss with your radiologist
o
Painless Macroscopic Haematuria
One or more of the following
 Negative urine culture and absence of red blood cell casts
 With normal renal function
 Normal ultrasound and cystoscopy
If you are unsure please discuss with your radiologist

MAMMOGRAM
One or more of the following
 If high risk screening
 If previous breast cancer – annually for 10 years then biannually thereafter. NB After 5 years can
re-enter BSA
 If new breast symptom, not lactating or pregnant and one of the following:
 Palpable lump and no normal mammogram in the last year
 Nipple discharge
 30 years and over (If under 30 – refer for Ultrasound)
If you are unsure please discuss with your radiologist

CT SCAN OF HEAD
o
Adult Headache Considerations
One or more of the following
 Headache with a normal ESR if >65 years old (some authors say 50)
46
 Without papilloedema
 If not pregnant or immediately post-partum
 Without fever, neck stiffness, suspected meningitis
 Without history of significant trauma
 Without thunderclap headache
 Not associated with normal migraine
CRITERIA: New headache and at least one of the following
 New headache in older population
 History of malignancy, or immunodeficiency
 Mental state changes
 Focal neurological deficit if not previously documented as a migraine
 Causing waking from sleep or worsened by Valsalva manoeuver
 Progressively worsening headache
 Seizure activity in non-epileptic
If you are unsure please discuss with your radiologist
CONSULTANT ADVICE LINES
TBA as per each DHB
DHB
Radiology Consultant Advice Line
Waikato
Bay of Plenty
Taranaki
Tairawhiti
Lakes
47
Glossary
Acronym
Meaning
AAA
Abdominal Aortic Aneurysm
ABCD2 score
Tool used for assessing the likelihood of stroke
ALT
Alanine Transaminase
AP
Antero-posterior
AST
Aspartate Transaminase
AXR
Abdominal X-ray
BMI
Body Mass Index
BSA
Breast screening Aotearoa
CRP
C- reactive protein
CT
Computerised tomography
CTU
Computerised tomographic urography
CXR
Chest X-ray
DHB
District Health Board
ED
Emergency Department
eGFR
(estimate) Glomerular Filtration rate
ESR
Erthrocyte sedimentation rate
GGT
Gamma Glutamyl Transferase
48
Acronym
Meaning
IUCD
Inter-uterine contraceptive device
LFTs
Liver Function Tests
MSU
Mid-stream urine
PCOS
Polycystic ovary syndrome
POAC
Primary Options for Acute Care http://www.primaryoptions.co.nz/
PUJ
Pelvi-ureteric junction
RBC
Red blood corpuscle [also cell / count]
ROM
range of movement
TIA
Transient ischaemic attack
US
Ultra sound
USS
Ultra sound sonography [US is a shortened version]
UTI
Urinary tract infection
WBC
White Blood Count [or White Blood Corpuscle /cell]
49
Appendix 2
Midland Primary Referred Radiology Access Criteria Prioritisation
July 2011
Subject to interpretation of clinical information in the referral and service capacity. Note that the
procedure should only be requested where the results (either positive or negative) will alter the
management of the patient’s condition/will either confirm or eliminate significant disease from the
differential diagnosis
Priority description
Timeframe
URGENT: - Where immediate treatment of acute
condition is dependent on diagnosis:
Imaging takes place within 7 working days.

High clinical probability of malignancy or
serious inflammatory/infective condition.

High clinical probability of fracture.

Major functional impairment including
uncontrolled pain.

Risk of significant permanent damage to
tissues or systems if diagnosis is
delayed.
SEMI-URGENT:
Conditions where there is possibility of
malignancy, serious inflammatory / infective
condition, and complications.
ROUTINE:
Conditions with minor functional impairment and
where imaging is unlikely to affect short term
management, but likely to affect long term
management.
DECLINED:
Imaging takes place within one month.

Referrals accepted if service able to be
offered within 6 months of referral.

Aim for imaging to occur within two
months (key performance indicator
measure)

Referrals meet criteria but are unable to
be offered within 6 months

Referrals do not meet the criteria
50
Appendix 3
Comparison primary referred radiology exams/RVUs across Midland DHBs
XRAYs
Shoulder
DHB
Exam code
Waikato XRSHOL
XRCLAR
BOP
XRSHOL
XRCLAR
Taranaki A06
A03
Tairawhiti A06
A03
Lakes
A04
Chest
DHB
Exam code
Waikato XRCHEM
XRCHES
BOP
XRCHEM
XRCHES
Taranaki C07
C06
Tairawhiti D06
D07
Lakes
D06
Ankle
DHB
Exam code
Waikato XRANKL
BOP
XRANKL
Taranaki A30
Tairawhiti B11
Lakes
B08
Exam description
Shoulder - Left X-Ray
Clavicle - Right X-Ray
Shoulder - Left X-Ray
Clavicle - Right X-Ray
Shoulder
Clavicle
SHOULDER
CLAVICLE
CR Shoulder Clavicle Right
RVU
1.3
1.2
1.3
1.2
1.3
1.2
1.3
1.2
1.3
Exam description
RVU
Chest Multiple views X-Ray
Chest Single Position X-Ray
Chest Multiple views X-Ray
Chest Single Position X-Ray
Chest (more than one projection)
Chest (single projection)
CHEST SINGLE VIEW
CHEST MORE THAN 1
CR Chest
1.3
1.3
1.3
1.3
1.3
1.3
1.3
1.3
1.3
Exam description
Ankle - Left X-Ray
Ankle - Left X-Ray
Ankle joint
ANKLE JOINT
CR Ankle Left
RVU
1.3
1.3
1.3
1.3
1.3
Exam description
Abdomen Ultrasound
Abdomen Ultrasound
US Abdomen
ABDO
US Abdomen
RVU
Exam description
Pelvis Ultrasound
Pelvis Ultrasound
US Female Pelvis
PELVIS
US Abdo / Pelvis
US Female Pelvis TV
RVU
Exam description
Shoulder - Left Ultrasound
Shoulder - Left Ultrasound
US Shoulder
RVU
US
Abdomen
Exam code
USABD
USABD
U01
U01
U01
Pelvis
DHB
Exam code
Waikato USPEL
BOP
USPEL
Taranaki U42
Tairawhiti U37
Lakes
U02
U42
Shoulder
DHB
Exam code
Waikato USSHOL
BOP
USSHOL
Taranaki U30
DHB
Waikato
BOP
Taranaki
Tairawhiti
Lakes
3.1
3.1
4
3.1
3.1
2.9
2.9
5
2.9
3.9
3.6
4.1
4.1
4.1
51
Taranaki U30
Tairawhiti U231
Lakes
U30
Scrotal
DHB
Exam code
Waikato USSCR
BOP
USSCR
Taranaki U21
Tairawhiti U21
Lakes
U21
US Shoulder
SHOULDER
US Shoulder
4.1
4.1
4.1
Exam description
Scrotum Ultrasound
Scrotum Ultrasound
US Scrotum & Testis
SCROTUM
US Scrotum and Testes
RVU
Exam description
Sinuses CT
Sinuses CT
CT Sinuses
SINUSES
CT Sinuses Mini Series
RVU
Exam description
Brain CT
Brain CT
CT Brain
HEAD NO CONTRAST
CT Brain
RVU
2.9
2.9
4
2.9
2.9
CTs
Sinus
DHB
Exam code
Waikato CTSIN
BOP
CTSIN
Taranaki T11
Tairawhiti T40
Lakes
R04
Head
DHB
Exam code
Waikato CTBRA
BOP
CTBRA
Taranaki T01
Tairawhiti T30
Lakes
R01
Chest
DHB
Exam code
Waikato CTCHE+
BOP
CTCHE
Taranaki T20
Tairawhiti T54
Lakes
R20+R30
Exam description
Chest + IV Contrast CT
Chest CT
CT Chest
CHEST UPPER ABDO
CT Chest and Upper Abdo
8.5
8.5
8.5
8.5
9.7
8.5
8.5
8.5
8.5
8.5
11.4
11.4
11.4
22.8
11.4
52
Appendix 4
REGIONAL ACCESS CRITERIA FOR PRIMARY REFERRED RADIOLOGY
SLAT MEMBERSHIP
Name
Title
DHB
Paul Malpass
Clinical Advisor
SLAT Chair
Roger Lysaght
Radiographer and Service
Manager Ambulatory Services
Lakes DHB
Mike Webb
Radiology Service Manager
Waikato DHB
Dr Alina Leigh
Consultant Radiologist
Taranaki DHB
Leigh Potter
Radiology Service Manager
Tairawhiti DHB
Kim McAnulty
Consultant Radiologist
Waikato DHB
Julie Wilson
Senior Funding Manager
Planning and Funding
Waikato DHB
Mike Agnew
Senior Portfolio Manager
Planning and Funding
BOP DHB
Navin Rajan
GP rep from Toi Ora PHO
Waikato
Michael Miller
Waikato Rural GP
Waikato
Paul Bond
GP
Taranaki
Giles Turner
GP
Lakes
Tom James
GP and Community Radiology
Rep
Tairawhiti
Mark Saunders
Business Development Manager
Network funder
MHN
Jane Hudson
Project Manager
Planning and Funding
Waikato
Also making a major contribution to the SLAT work and final report
Jill Wright
Radiology Manager
BOP DHB
53