Where Is the Alignment Behind Decision Support?
Liz QuamThe lack of consensus (and vision) in the imaging community is readily apparent when the topic of clinical decision support is raised. Clinical decision support allows for electronic documentation of the appropriateness of the imaging service ordered and provided, offering clinicians real-time guidance, rather than black-box rules. Clinical decision support improves efficiency by eliminating the administrative burden experienced by the ordering clinician and the imaging provider under radiology benefit management (RBM) companies. While it is a win–win proposition for the providers and the payors, the ultimate winner is, of course, the patient, who receives assurance that the wisest course of treatment has been delivered, whether it is two weeks of aspirin, radiography, or an MRI exam with and without contrast. There are decision-support naysayers within the imaging community who are concerned that clinical decision support will reduce the number of tests they perform. Certainly, these worries have some validity. The initial data from Minnesota, where clinical decision support is now widespread in the provider community, indicate that single-modality centers have seen a decrease in volume. There is some indication that this is because clinical decision support has guided treating clinicians to order a test using a different modality, ultimately saving some patients the cost and time of inconclusive results from the first (inappropriate) exam. Why isn’t our whole imaging industry focused on documenting that the right test is provided, at the right time, by the right provider? Our collective voice is weakened by the actions of a minority whose members resist change—and in the absence of consensus, the RBMs have flourished. A Short History When the DRA delivered radiology a nearly fatal financial blow, some radiologists and their imaging-industry partners focused even more intensively on holding on to every patient that they could, while pointing fingers at medical specialists who are essentially doing the same thing: hanging on to every piece of health-care business that they can legally sequester. In contrast, others in the industry absorbed the DRA and collectively sought viable alternatives to the perceived and/or real concerns of government and commercial payors. We want to avoid further devastating reimbursement cuts and more mother-may-I telephone calls to RBMs. We are collaboratively seeking to assure the purchasers of diagnostic imaging services—whether patients, employers, health insurers, or government—that they are receiving appropriate, value-added health-care services. At Center for Diagnostic Imaging (CDI), Minneapolis, Minnesota, an initial, proactive step that we took, after the DRA, was to advocate for consistent standards for the technical portion of a diagnostic imaging test. The founder of CDI, Kenneth Heithoff, MD, chaired the UnitedHealthcare® medical advisory group, which resulted in UnitedHealthcare’s adoption of accreditation standards for imaging providers, a development that received a mixed reception in the outpatient imaging center community. Thanks to the efforts of the ACR® and other members of the Access to Medical Imaging Coalition (AMIC), including the Association for Quality Imaging, the 2008 federal Medicare bill followed the lead of UnitedHealthcare in mandating accreditation standards for Medicare imaging providers. This program offers reasonable assurance (where none existed previously) that the imaging provider will at least perform the test correctly. With the exception of the accreditation standards and clinical decision support, we haven’t been able to identify significant, viable methods to assure the patient, employer, or payor further that the diagnostic test being ordered is appropriate. The eOrdering Coalition Therefore, adoption of clinical decision support should be the imaging industry’s collective focus, until we have deployed clinical decision support nationwide and quieted the cacophony over the growth of diagnostic imaging. This is the goal of the eOrdering Coalition, a foresighted and energetic group of industry leaders/thinkers who, together, battled to kill President Obama’s 2009 call to hire an RBM for all of Medicare. We made several visits to Congress to communicate that this would create cranky-physician syndrome nationwide (which politicians prefer to avoid, prior to an election); provide no added value to the health-care service being provided; be administratively burdensome to providers—with our emphasis being on the burden to family physicians; and seriously muck up an already-cumbersome system because Medicare would have to add an appeals department to handle all the appeals filed when the RBM denied coverage (this seemed to generate the most attention in Washington). Thanks again to the help of the AMIC and the ACR, we were successful in keeping RBMs out of the Patient Protection and Affordable Care Act. This, however, was only one skirmish in the imaging industry’s battle for survival. Much more needs to be done, including the integration of clinical decision support into the meaningful-use standards for health IT. To that end, CDI was an early adopter of clinical decision support in our Minnesota market, where clinical decision support will soon be deployed throughout the state, including rural areas (one state down; 49 to go). Based on data from our state’s three largest commercial insurers, utilization of diagnostic imaging services has been reduced, especially at single-modality centers, pleasing state officials who oversee our Medicaid program. Ordering clinicians are accepting the program, which is available as an embedded tool for computerized provider order entry for some hospital-based physicians and at the point of scheduling/service for other providers. Our state’s large-employer coalition is highly supportive. Imaging providers, such as CDI, are vocal proponents because we have moved from the defensive to the offensive line: We have electronically documented the appropriateness of the services that we have provided. While many other areas of the country are now in early decision-support deployment, there is much more that needs to be done. We must quiet the naysayers among us. We must find ways to erode the hold that RBMs have on some of our biggest insurers—which are not yet convinced that they should eliminate this internal profit center. Together, we in the imaging industry must continuously strive to find ways to assure our patients that they are receiving the best, most appropriate care from us every time they visit a radiology department or an outpatient imaging center. Liz Quam is executive director, CDI Quality Institute, Center for Diagnostic Imaging, Minneapolis, Minnesota; lquam@cdirad.com.