Clinical Decision Support: A Radiology Practice’s Approach

There has been much written and discussed over the past few years regarding clinical decision support (CDS), or the ”hard stop” approach to managing imaging ordering appropriateness. Though it’s been on everyone’s minds, and some have implemented CDS as a strategy to improve prior authorization, the discussions were never really of true consequence for private practices and their reimbursement outlook until March of this year, when the Senate passed the Protecting Access to Medicare Act of 2014 (H.R. 4302), also known as the Sustainable Growth Rate patch legislation. The passing of this act was applauded by many in the radiology industry because it delayed, yet again, the 24% Medicare physician payment cut for another 12 months. However, it also mandated that ”claims that fall under the appropriate use criteria requirement will only be paid if they include data that indicate CDS tools were consulted.” This statement has left many groups wondering, how will CDS affect my practice and the practice of my referring physicians? How will it affect consultative relationships?

My radiology practice unknowingly started preparing for the CDS mandate back in 2010 when our practice identified an opportunity for clinical improvement. We had been receiving continual feedback through our results communication call center (RCC) that referring physicians frequently had questions about what exams to order and when to order contrast. The RCC is a 24/7/365 clinical call center that referring physicians can use to reach a radiologist for consults. The team is also responsible for 18,000 inbound and outbound calls regarding patient reports, STAT or otherwise, which puts them in an ideal position to receive questions and feedback about suggested follow-up exams.[[{"type":"media","view_mode":"media_crop","fid":"29177","attributes":{"alt":"Amanda McNutt","class":"media-image media-image-right","id":"media_crop_8084413645865","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3027","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 224px; width: 160px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Amanda McNutt, VP of Operations, Columbus Radiology","typeof":"foaf:Image"}}]]

After analyzing the most frequently asked questions that came to our RCC call center, our team set about designing tools that would help referring physicians learn how to order the correct exam. Our goal was to position ourselves as true consultants, providing useful information to our referring physicians that would drive more accurate ordering, which ultimately results in better reports and outcomes for patients.

Using the 80/20 rule, we decided to focus our efforts on ordering guidelines for primary care physicians since the majority of our questions came from this population. Developing the guidelines was a painstaking process with each subspecialty section head weighing in on which diagnoses to comment on. This was a 10-month authoring process. The content is organized by area of the body, then by common diagnosis or symptom, and then each exam is listed with the pros and cons. The favored exam is listed first with the remaining listed in preferred order.

After organizing our content online, we developed two learning settings for our referring physicians: traditional CME presentations and online access through our imaging ordering guidelines app.

Our initial CME offering, a 2-hour dinner meeting, was completely booked in 10 days. We knew at that point that we were closing a knowledge gap for our referring physicians. The event was well-received and we went on to educate over 360 providers through various events, with one meeting drawing over 100 participants.

Our imaging ordering guidelines app was also very well received. Physicians in practice and in training added the app to their cell phones and are able to access the information daily at the point of care. Physicians can also browse content during their off- time. The current drawback and area of interest is the app is not tied to the EMR.

As you can imagine, our group has only benefitted from making the effort to educate our referring physicians on what exams to order. Not only does it improve patient care and reduce waste and rework, it strengthens our relationships with our colleagues, our referring physicians. It has also positioned us very well to head in to the CDS environment. We hope that our efforts will, to a certain extent, mitigate some of the anticipated frustration providers will experience in the “hard stop” environment.

Above and beyond the ordering guidelines tools we have made available to our referring physicians, we also continue to place emphasis on the availability of our radiologists for consult. Through our results communication call center, referring physicians (or their staff) can call any time of day to discuss a patient and which exam would be the most appropriate given the diagnostic need. Sometimes, as we all know, referring physicians have a question that no app, CDS software, or CME event can answer, and in those cases we are available 24/7/365 to do what we do best, consult with our referring physicians.