The Clinical Decision-support Mandate: Now What?

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 - Brain

An act of Congress opened the door for clinical decision-support for advanced imaging in U.S. hospitals: The radiologist is key to the initiative’s success

Clinical decision-support (CDS) software that analyzes and ranks the appropriateness of a physician’s order for a diagnostic imaging exam has been a laggard on the health IT technology adoption curve. But this will change, thanks to an act of the U.S. Congress.

It’s not that radiology CDS based on best-practice guidelines isn’t a great idea. Articles by early adopters published in peer-reviewed journals have demonstrated the ability of CDS integrated with computerized physician/provider order entry (CPOE) systems to reduce the number of inappropriate exams, thereby improving the quality of healthcare by reducing unnecessary exposure to radiation dose and also reducing costs.

Health IT investments of higher priority to hospitals—certified electronic health record (CEHRT) technology needed to comply with the federal meaningful use (MU) program, better security systems, and ICD-10 conversion software—have superseded investments in radiology CDS. It’s been a carrot without a stick to push it—until the passage of the Protecting Access to Medicare Act (PAMA) of 2014 in April.

The bill sought to authorize a short-term Medicare SGR patch that extends authorization for physician reimbursement under Medicare under current law through March 31, 2015. The bill prevents a scheduled 24 percent reduction in Medicare physician reimbursement rates.

It also mandates that starting January 1, 2017, physicians ordering advanced diagnostic imaging exams (CT, MRI, nuclear medicine and PET) must consult government- approved, evidence-based appropriate-use criteria, namely through a CDS system. Physicians furnishing advanced imaging services will only be paid if claims for reimbursement confirm that the appropriate-use criteria was consulted, which CDS mechanism was used, and whether the exam ordered adhered or did not adhere to an acceptable CDS rating. It’s important to note that physicians ordering advanced diagnostic imaging services do not have to adhere to the appropriate-use criteria; however, they must confirm that the guidelines have been consulted.

Consultation of appropriate-use criteria is required prior to the ordering of advanced diagnostic imaging services in the physician office, hospital outpatient, and emergency department settings. Exams for inpatients and emergency services as defined under the Emergency Medical Treatment and Active Labor Act (EMTALA) will be exempt. Hardship exclusions, such as a lack of access to high speed Internet, will be allowed, presumably on a case-by-case basis.

The U.S. Department of Health and Human Services (HHS) through CMS is authorized to deem various accepted appropriate-use criteria by November 15, 2015. The law, however, further specifies that the appropriate-use criteria can only be “developed or endorsed by national professional medical specialty societies or other provider-led entities.” Furthermore, the legislative language stipulates that the criteria must be scientifically valid, evidence-based, and based on studies that are published and reviewable by stakeholders. Similar to agency approvals of health IT software for the meaningful use program, CDS systems must be vetted and deemed acceptable by HHS no later than April 1, 2016.

The CDS awareness campaign

The inclusion of mandatory use of CDS when ordering advanced imaging exams didn’t happen by accident. ACR and the Imaging e-Ordering Coalition have been promoting the use of CDS as an alternative to pre-authorization favored by radiology benefit management (RBMs) companies, at least since the coalition was founded in 2009.

The Imaging e-Ordering Coalition, of which ACR was a founding member, is an alliance of healthcare providers, radiology and health IT vendors, and diagnostic imaging organizations. Its primary objective was to establish a national initiative to promote health IT-enabled decision support for ordering appropriate diagnostic tests.

Members of the e-Ordering Coalition worked to educate government agency and Congressional policy makers and healthcare providers about the benefits of integrated CPOE/CDS. It acted as a resource for the CMS with respect to the Medicare Imaging Demonstration Project that was funded as part of the Medicare Improvements for Patients and Providers Act of 2008 (MIPAA).

Data collection from the $10 million, three-year project that started