Clinical Decision Support: Planting a Decision Tree in Radiology

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After a six-month period of collecting baseline data, the CMS Medicare Imaging Demonstration began on April 1, 2012. The imaging industry is watching this test closely. If the two-year demonstration shows that a computerized decision-support system can guide referring physicians to make appropriate orders for advanced imaging tests—and, at the same time, curtail inappropriate utilization—then a move to impose prior-authorization requirements for advanced imaging exams for Medicare patients might be headed off at the pass.

Even if the Medicare Imaging Demonstration fails to squelch a call from the Obama administration and its allies to use radiology benefit management companies (RBMs) to screen advanced imaging orders for Medicare recipients, the demonstration project represents a watershed event. There has been a push (inside and outside CMS) since 2005 to reduce costs for CT, MRI, and other advanced imaging exams. Computerized radiology decision support—a sort of soft blockade in the path of the ordering physician—is seen as a way of accomplishing this.

In fact, the RBMs themselves are embracing computer-aided radiology decision support and are building it into their prior-authorization methods. They are already experimenting with hybrids of electronic decision support and human intervention that are certain to become familiar to ordering physicians.

As Curtis Langlotz, MD, PhD, notes, there is really nothing unusual about decision support finally being invoked for imaging orders. “Decision support has been around for decades,” Langlotz says, “and it has been shown to be effective in modifying physician behavior. This represents radiology taking advantage of decision-support technology that has been widely used in other disciplines.”

In hospital laboratory and pharmacy ordering, decision support is routine, and cardiology now is implementing decision support at a rapid pace. Langlotz says that decision support also guides physicians in dealing with allergic conditions when prescribing drugs or ordering screenings. “I think these are tools that help radiology practices and other health-care institutions manage imaging in a rational way, and I think they will be used increasingly for the accountable care that we deliver,” Langlotz adds.

Langlotz, who is vice chair for informatics in the radiology department of the Hospital at the University of Pennsylvania (Philadelphia), is a participant in the Medicare Imaging Demonstration, as part of a group that includes three other academic hospitals in the Northeast. CMS has selected four other groups to participate in the Medicare Imaging Demonstration. The agency calls the participants conveners because each one convenes referring physicians to join the demonstration.

Langlotz emphasizes that the groundwork being laid with radiology decision support through the Medicare Imaging Demonstration is most likely to find its payoff as health systems transition to accountable-care organization (ACO) models. “We were interested in decision support because we see it as a good way to get patients the right test, at the right time, as we move toward accountable care,” Langlotz says. “We are using the Medicare Imaging Demonstration as a way to get some early experience for ourselves.”

Getting early experience with decision support through the Medicare Imaging Demonstration is a recurring theme with Medicare Imaging Demonstration conveners. Even though it is focused only on fee-for-service Medicare outpatients, the Medicare Imaging Demonstration is generating excitement because it is testing radiology decision support across a wide range of provider groups that have no common financial incentive.

If decision support works for the Medicare Imaging Demonstration, then it ought to work anywhere. If the Medicare Imaging Demonstration’s results show that decision support guides ordering physicians toward appropriate imaging exams and away from inappropriate exams, then Langlotz and others who believe that decision support can replace RBM prior authorization might feel vindicated.

Physician and Patient Friendly

A recent study¹ looked at combined computerized provider order entry (CPOE) and decision support use in both outpatient and inpatient settings. The study found that CPOE with embedded decision support achieved a high level of use from ordering physicians, with 95% acceptance at the end of 10 years. It also found that the need for preauthorization decreased with the integration