Clinical Decision Support: Lessons Learned from the MID Project

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The experiences of two of five conveners in the Medicare Imaging Demonstration indicate that the challenges of implementing decision support for radiology go well beyond the technical.

Coming in 2017, physicians treating Medicare patients must consult clinical decision support (CDS) prior to ordering advanced imaging for Medicare beneficiaries as mandated by Congress in 2014; four years prior, Congress had required CMS to conduct a demonstration project to assess whether CDS could assure that patients receive the imaging study required for their care, explicitly excluding the cumbersome method of choice at the time—pre-authorization.

Several months ago—and quietly into the breach—CMS delivered a report on the results of that demonstration to Congress. The report’s author and three of eight participating organizations presented the very timely “Clinical Decision Support: Lessons from the Medicare Imaging Demonstration (MID),” on December 2, 2014 at the annual meeting of the Radiological Society of North America (RSNA) in Chicago.

At the outset, moderator Ramin Khorasani, MD, PhD, underscored not just the stakes in meeting Congress’s 2017 CDS implementation deadline, but (given the MID results) getting it implemented correctly: “Beginning January 2017, if ordering physicians are not exposed to certified CDS when they order the exam, the radiology practices that perform the exam will not be paid,” he emphasizes. “If you can’t get this in in time, it will be quite the show, let’s say.”

The MID project was mandated by the Medicare Improvements for Patient and Providers Act of 2008; designed by CMS and the Lewin Group to present CDS as an alternative to pre-authorization; and undertaken by five conveners who enrolled between 8,000 and 8,500 physicians between October 2011 and September 2013. The conveners were the Brigham & Women’s Hospital consortium (which included Geisinger Health System, University of Pennsylvania Health System and Weill Cornell Medical College), Henry Ford Health System, Maine Medical Center, National Imaging Associates and University of Wisconsin Health System.

“MID assessed the impact of CDS based on very specific pre-selected professional society guidelines of 12 targeted high-cost outpatient imaging procedures for Medicare fee-for-service patients—but specified that physicians could ignore the guidelines and refer patients to any imaging provider they wished,” Khorasani explains. There were no restriction on services, and physicians received comparative data on their use of the specified imaging exams in relation to their peers.

The setup

Katherine Kahn, MD, is professor of medicine, University of California, Los Angeles, and senior scientist with the RAND Corporation Santa Monica, Calif. office, which performed the analysis of the national proof data. She served as the principle investigator and project director for the evaluation of the MID. 

“I can tell you that when I assumed responsibility for the evaluation of the MID, I knew it would be an interesting and important project,” she begins. “I had no idea it would take on the significance that I think it will based on the new PAMA legislation.”

The goals of the MID evaluation (EMID) were to quantify the rates of appropriate, uncertain and inappropriate orders and to determine whether exposing physicians to guidelines at the time of the order was associated with more appropriate ordering and with changes in utilization.

Khan notes that within the MID, the practices that participated utilized CDS systems that fell into two broad categories of decisions-support software (DSS) design: One required users to select the patient characteristics and the clinical indications for an order; with the other type of system, users were prompted by a series of structured queries to document clinical information relevant to an order.

An implementation team at CMS selected the targeted images using three criteria: advanced images with high volume; availability of clinical AC developed or endorsed by a medical specialty society; and variation in utilization rates between rural and urban areas. They included MR and CT of the brain and lumbar spine; CT of the sinus, thorax, abdomen, pelvis and combined abdomen/pelvis; and MR of the shoulder and the knee; and SPECT MPI. ACR Appropriateness Criteria were the exclusive AC used for six of the procedures and AC from six other sources were associated with the other seven procedures.

Clinicians used radiology order entry