Maximum Efficiency, Minimal Intrusion - 7 Steps Toward Optimized CDS Implementation

When CMS finally named a firm start date for its clinical decision support (CDS)/appropriate use criteria (AUC) program last November—financial incentives for appropriately using CDS will kick in Jan. 1, 2018—two key stakeholder groups finally had information they'd been wanting for quite some time.

CDS software developers now had guidance and a green light for submitting applications to get their products CMS-qualified. With a submission deadline of March 1, the agency plans to announce which products—or CDSMs, the M standing for mechanism in CMS parlance—qualify by June 30. 

And radiology now had more information to go on than at any time since 2011, when CMS first promised guidance would be coming. Speaking on the specialty’s behalf, the American College of Radiology quickly issued a statement expressing gratitude for the clarified timeline and relief for a clause stating that the program “will apply to orders for all advanced diagnostic imaging services, not limited to priority clinical areas.”

Of course, CDS has its detractors. A study published in the Journal of the American Medical Informatics Association last spring showed that CDS systems frequently malfunction, with the difficulty in detecting alerts that fail to fire a particularly knotty problem to solve. (J Am Med Inform Assoc. 2016 Nov;23(6):1068-1076)

However, most stakeholders seem to appreciate CDS as a promising young technology that is growing up fast. The CMS process for qualifying CDSMs is expected to go a long way toward maturing use methods and advancing best practices, and the widespread provider adoption leading up to Jan. 1, 2018, has already created quality-improvement momentum to build on.

What will separate CDS successes from missteps? The degree to which it’s properly implemented by providers, according to three CDS experts who spoke with Radiology Business Journal to offer tips and pointers on understanding, selecting, implementing and maybe even learning to love CDS.

Here are some of their suggestions.

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1 Going in, know that there are two “main flavors” of CDS.

One type of CDS essentially places patient cases into “buckets” containing demographically similar patients presenting similar symptom profiles, then recommends the exam that has worked best for said profiles in the past. The other prompts the CDS user with iterative questions: If you enter insufficient information for the system to figure out the next best step, it fills in the gaps by asking a series of follow-up questions.

“The iterative approach is more intrusive. It entails more clicks,” says Keith Hentel, MD, MS, of Weill Cornell Medicine in New York City. “But it also tends to be more precise. So there’s a trade-off that has to be considered.”

Much of Hentel’s CDS know-how comes from Weill Cornell’s participation in the Medicare Imaging Demonstration (MID) that ran from October 2011 to September 2013. He was also the co-author of an article about CDS implementation in the American Journal of Roentgenology (AJR Am J Roentgenol 2014;203[5]:945-51).


2 When selecting your CDS solution, look for one that uses evidence-based logic to determine the appropriateness of the imaging order.

Optimal CDS software targets specific clinical scenarios on which high-quality evidence exists, says radiology resident Patricia Balthazar, MD, of Emory University in Atlanta.

The solution should support hyperlinking to the evidence, as “transparency is very important if ordering physicians are to accept and use CDS,” adds Balthazar, who recently completed a research fellowship at the Center for Evidence-Based Imaging at Brigham and Women’s Hospital in Boston. In her time there, she served as project manager for the Harvard Library of Evidence, a provider-led public repository of medical evidence that can be used as CDS content.

“Optimal CDS tools not only measurably reduce inappropriate imaging utilization,” says Balthazar. “They also improve adherence to evidence.”


3 Choose CDS software that is intuitive, includes macro capabilities for frequently used terms and fits within the ordering physician’s workflow.

“It should specifically include a preauthorization module,” says Mark Hiatt, MD, MBA, who knows CDS from both the provider and payer sides. A former practicing cardiovascular radiologist, he now works as executive medical director of Regence BlueCross BlueShield of Utah.

“The CDS tool shouldn’t be distinct or separate from the physician’s workflow,” Hiatt says. “It needs to integrate with that workflow to streamline the process and make it efficient for the ordering provider.”

Hentel adds that CDS is “intrusive by nature. You’re sticking an additional step into the ordering process. Good CDS minimizes the intrusiveness of the interaction.”


4 Look for a product that taps patient information available in the EHR—and doesn’t “tap” the ordering physician unless it has actionable information to offer.

“When we did the MID, it had no EHR integration,” says Hentel. “When you keyed your problem list into the EHR—‘the patient has X, Y and Z’—and then you went to do a decision-support interaction, you would have to retype those same indications again. Smart software makes use of information within the EHR and then also sends information back to the EHR.”

As far as actionable info is concerned, Balthazar says the CDS alerts must tell the ordering physician that the order either needs to be canceled or changed to a different exam. Alerts that give virtual pats on the back for appropriately ordered exams will have the opposite of the intended positive-reinforcement effect.

“If it’s not actionable, it adds to alert fatigue,” Balthazar says. “It also adds time and steps that don’t add up to anything meaningful,” increasing its annoyance quotient—never a good thing for a new technology trying to win widespread adoption.

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5 Make the implementation multidisciplinary, but make sure radiology takes the lead. 

According to Hentel, CDS implementation is something that can’t just come out of radiology, because a consensus must be reached on which appropriate-use criteria will be followed. Since radiologists are the experts on imaging, however, it does make sense for them to lead that conversation.

“There is no other group that knows imaging like radiology does,” he says. “So it’s completely appropriate and probably necessary that radiologists are the people coordinating the multidisciplinary efforts to select and implement CDS tools.”

Balthazar agrees with this sentiment. “We’re the ones adding the content and keeping it up to date as new evidence comes in,” she says. “That is very important. You have to have a radiologist for that.”

Hiatt, however, isn’t so sure. He says CDS is an opportunity for ordering physicians to take more responsibility, since they play such a central role in the beginning of the process.

“If it’s real-time, automated, streamlined and integrated into the workflow, CDS can actually lessen the burden of referring physicians,” he says. “It can ensure that they get the right test at the right time—and that it’s an exam the radiologist feels confident performing.”



6 In daily use, CDS may well exacerbate any existing tensions between referrers and radiologists. See this as an opportunity rather than a problem.

There will always be people who complain about new processes. But this can be a good problem to have—nearly every complaint represents a chance for discussion.

“I have many multidisciplinary collaborations now that I didn’t have before,” Hentel says. “People are looking at their practices in all our departments. CDS implementation has given us [radiologists] a chance to get out there and to show our knowledge and to help with the management of this technology. Do I worry about putting people off? Yes, but this is outweighed by the opportunities for radiology as a whole and for individual radiologists to help our referrers and help our patients.”

According to Balthazar, conflict also is likely to arise between any physician groups and IT departments.

“Clinicians don’t want to lose their autonomy, and sometimes CDS puts a hard stop in a clinician’s imaging order,” she says. “They’re smart people and knowledgeable in their clinical field. The best approach is making sure the CDS tool gives them the option of ignoring the alert. They have to be able to do that.”

Some CDS tools include a capability for ordering physicians to tell why they chose to ignore an alert, whether in a free-text field or by drop-down menu.


7 Over the long haul, CDS will prove its value. Enjoy its benefits as you manage its issues.

“CDS gives radiologists better control of their own destiny,” says Hiatt. “They can have more control of the workflow, revenue, referral networks and patient caseloads,” he adds, stipulating that the CDS has to be well chosen and properly implemented. “I don’t know of any radiologist who would object to greater precision in ordering on the part of their referring physicians. Everyone benefits—most of all the patient.”

“In our day-to-day work, we see inappropriate exams being ordered,” says Balthazar. “We see duplicate studies. And everyone wants to avoid giving suboptimal care to our patients. As healthcare providers, if we can do something to help optimize order entry with decision support, adopting the CDS tool in an optimal way, we will be very helpful in the cause of improving patient care while containing costs.”

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One issue leaders can prepare for during CDS implementation is culture change, and this need will be especially acute in places where clinical decision support is an entirely new concept.

“It’s a big change, it’s additional work, and physicians don’t like Big Brother looking over their shoulder telling them what to do,” says Hentel. “So you do have to manage the [transition period]. But CDS can be used not just to make sure you comply with evidence-based guidelines but also to make sure physicians are ordering the right exam the first time.”

At Weill Cornell, Hentel notes, more appropriate exams are being ordered the first time as a result of CDS. And this means less time is being spent correcting instances where an incorrect exam was ordered.

“It just has to be done right,” he says. “If you can eliminate unnecessary procedures—if you can make sure that workflow is optimized by people ordering the right procedure at the right time—that’s absolutely a good thing.”