Radiology Can Lead the Way in Clinical Decision Support

CHICAGO - A law passed earlier this year will mandate the use of electronic clinical decision support (CDS) to order imaging studies by 2017. To be reimbursed by the Centers for Medicare and Medicaid Services (CMS) for imaging studies, radiologists will have to document that a CDS was used when the study was ordered.

The implications of the Protecting Access to Medicare Act (PAMA) of 2014 for radiologists and a CMS imaging decision-aid demonstration project were discussed at the Radiological Society of North America’s annual meeting at the session “Clinical Decision Support for Imaging: Update on Current State and New Federal Regulations.”

The federal efforts are intended to reduce overutilization that can drive up health care costs and expose patients to unnecessary radiation.

“Imaging has gone up, and we lead the pack in costs in medicine,” said Keith Hentel, MD, MS, chief of the division of emergency/musculoskeletal radiology and executive vice chair of the department of radiology at New York-Presbyterian Hospital-Weill Cornell Medical Center. “Radiologists and our practices have become targets.”[[{"type":"media","view_mode":"media_crop","fid":"30201","attributes":{"alt":"alert","class":"media-image media-image-right","id":"media_crop_3642049726788","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3155","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: 106px; width: 160px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":" ","typeof":"foaf:Image"}}]]

Hentel noted that some private payers have created radiology benefits management (RBM) programs to reduce unnecessary imaging by requiring prior authorization. But Hentel said there is limited data on the effects of this approach. He noted one study found reduced utilization with RBMs and another that suggested that prior authorization simply shifts more costs to radiologists and ordering physicians’ offices.

Another approach to reduce overutilization and improve quality of care recommended by the Institute of Medicine and others has been to make greater use of CDS systems that can extract data from relevant clinical guidelines and medical studies available to physicians in real-time to help guide their choices.

To test whether CDS could improve physicians’ use of imaging studies, CMS funded the Medicare Imaging Demonstration project conducted at 31 practices with 5128 physicians serving more than 79,000 Medicare beneficiaries. Preliminary data were presented recently and will likely help shaped the implementation of PAMA.

Brigham and Women’s Hospital and its affiliates have been testing the use of CDS. Ramin Khorasani, DMD, associate professor of radiology at Harvard Medical School and director of information management systems at Brigham and Women’s Hospital in Boston, explained that the institution’s electronic medical records systems have been linked with an electronic evidence library that includes clinical guidelines from the American College of Radiology (ACR), the American College of Emergency Physicians, the American Board of Internal Medicine Foundation’s Choosing Wisely Campaign, and many other guidelines. When a physician begins the process of ordering an imaging test, the system guides the physician to answer a series of questions. Then, it provides the physician with evidence about whether the test is warranted. If the physician ignores the system’s recommendation, an automatic radiology consult is ordered to discuss the need for the test.

Khorasani said the program has reduced the number of magnetic resonance imaging tests for patients with low back pain ordered on the day of the patient’s visit to their primary care physician by 30% and has reduced the number of computed tomography scans for minor brain injuries in the emergency department by 13.4%.

“It’s important to think of it as a clinical program,” Khorasani said. He explained that involving leadership and physicians in the program has been essential.

The ACR has embraced decision support tools as part of its Imaging 3.0 initiative. The college has created ACR Select, a CDS system based on ACR Appropriateness Criteria. The system can be accessed through a website or used by electronic medical record vendors.

“We need to undergo a transformational change,” said Bibb Allen Jr, MD, chair of the ACR’s board of chancellors. He explained that the college is working toward a culture change in the profession and it is working to build the tools and incentives needed.

Allen noted that while the initial phase of PAMA targets decision support tools for imaging, later phases will involve other specialties. By being the first specialty to implement widespread use of decision support, radiologists are positioning themselves as leaders and strengthening their relevance, Allen said.

“Wouldn’t we rather not do the things that don’t matter and promote the ones that do,” he said.