The State of Clinical Decision Support

Many advances have been made since the Medicare Imaging Demonstration was implemented in 2009.

While research on clinical decision support (CDS) for advanced imaging—including the recently issued report on the 2009–2011 Medicare Imaging Demonstration (MID) project—continues to provide information for improving the overall CDS process, it should be noted that CDS as a practical, everyday tool for imaging ordering has evolved substantially, providing real-world change in advance of RAND Corporation’s conclusions about MID and CDS for advanced imaging.  In addition, industry coalitions have worked to lay the groundwork for a standard, efficient CDS process.  

Consider some of the practical improvements made to CDS over the past two years. First of all, the breadth of appropriate use criteria (AUC) continues to grow. The ACR’s CDS content library contains a significantly expanded set of clinical scenarios versus the criteria used in the MID. Similarly, the American College of Cardiology’s guidelines cover at least 90% of the scenarios for cardiac imaging.1  More appropriateness content and better algorithms mean fewer instances where guidance is uncertain. This hard work is at the core of creating reliable, clinically relevant content for CDS.

In addition, CDS mechanisms are now interfaced with many of the major EHR vendor systems, placing the process of using CDS within the main application of the ordering physician. This creates an easier and more reliable process for initiating CDS at the point where it is most helpful. Thanks to active industry volunteer workgroups, the imaging order now also is being standardized so that it can be utilized consistently throughout the healthcare enterprise. 

Provider and industry stakeholders are working with Integrating the Healthcare Enterprise on two new profiles that include the handling of CDS data.  As a result, the required CDS information will move from ordering provider to rendering provider electronically. Standard dictionaries for key data elements are being established, a critical step in supporting an efficient CDS process.

In its Report to Congress,2 RAND generally concluded that conveners had an unexpectedly high percentage of unrated orders, suggesting technical problems in the way conveners mapped decision support systems (DSS) to guidelines. While appropriateness levels improved substantially after DSS feedback was turned on, there was little change in overall utilization. Physicians did not believe the software linking the user interface and guidelines was adequately developed to engage clinicians in a meaningful way.

Encouraging findings

The RAND report did include several encouraging findings. Evidence supported the fact that clinicians do respond to “concurrent feedback showing them imaging strategies that can serve as alternatives to the original orders.”2

“The appropriateness of advanced imaging orders that were assigned appropriateness ratings increased by about 7 percentage points between the baseline and intervention periods,” the authors wrote. 2

“These increases in appropriateness are indicative of a successful intervention to the extent that advanced imaging orders can be successfully rated for appropriateness.” 2

MID does offer areas for improvement with integrating appropriateness criteria into tools designed to assist physicians with medical decision making. It bears repeating, however, that much improvement in CDS and related systems has occurred, and continues to occur, since the time of MID. Evaluating CDS based on solutions available in 2008 would be analogous to evaluating the functionality of the iPhone® 6 based on the specifications of the original model.

The bottom line for the healthcare industry on CDS is that we have a mandate to implement a standard, efficient process in the next two years.  Effective January 1, 2017, Medicare claims for advanced diagnostic-imaging services (CT, MRI, nuclear medicine and PET) must contain specific CDS information for payment. Imaging ordering will utilize CDS tools that have algorithms that allow real-time access to AUC developed by specialty societies or other provider entities.

With two years to go before implementation, CDS advocates, healthcare system vendors, IHE and the Imaging eOrdering Coalition have made great strides towards operationalizing the CDS mandate.  Indeed, CDS has advanced significantly since the 2009–2011 MID project.

Note: References are available online at

Michael Mabry is executive director of the Radiology Business Management Association and co-chair of the Imaging e-Ordering Coalition; and Julie Pekarek is a member of the Imaging e-Ordering Coalition and co-chair of the workgroup on standardizing the imaging order.

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