Decision support rules for radiological exams will buffet providers

Healthcare organizations will face many challenges in preparing radiologists and information systems for the transition to a new program that will require physicians ordering outpatient radiological procedures for Medicare beneficiaries to justify imaging exams.

With the transition set to begin in seven months, on January 1, organizations that have tested the approach say workflow changes are disruptive, and are likely to slow radiologists down. Mapping clinical decision support rules into electronic records systems is difficult but one of the better ways to incorporate the new payment requirements.

The reimbursement approach aims to have physicians refer to industry-developed appropriateness criteria before ordering advanced—and expensive—imaging procedures for patients, using clinical decision support modules tied into EHRs.

The program is one of the provisions of the Protecting Access to Medicare Act of 2014. Even though the start is only a few months away, many specifics of how the program will work are still in development. However, organizations need to begin planning now and not hope that they’ll get a reprieve from federal agencies, said presenters at a session during the annual meeting of the Society for Imaging Informatics in Medicine.

“Some of you may say that there's no way this will go live in January,” says Kevin McEnery, MD, director of innovation in imaging informatics at the The University of Texas MD Anderson Cancer Center. “You can roll the dice, but if the new system goes live, you'll never make it.”

The use of criteria is expected to be applied to imaging studies ordered for outpatients for eight types of studies, termed priority clinical areas—coronary artery disease, suspected pulmonary embolism, headache, hip pain, low back pain, shoulder pain, cancer of the lung, and cervical or neck pain.

An early test of the approach by Weill Cornell Medicine through a demonstration project encountered challenges because a study showed that only 5 percent of interacctions with the clinical decision support approach improved care for patients, says Keith Hentel, MD, chief of emergency and musculoskeletal imaging and vice chairman of clinical operations of NewYork-Presbyterian Hospital.

“If you’re going to implement decision support, you’re better off eliminating what's inappropriate because there's more agreement by clinicians on that,” he said. In its demonstration project on the new system, physicians were not satisfied with the new approach, Hentel says. “I’ll show you the scars on my back. At Weill Cornell, our physicians were not happy. We were making recommendations against what were considered local best practices.”

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The program will have significant effects on ordering physicians, radiological professionals and healthcare organizations, which will need to add imaging-specific modules to their EHR systems and adjust workflows. In addition, it could impact payments for radiology professionals in 2018 and force a small percentage of physicians who regularly override appropriateness criteria to seek pre-authorization for studies beginning in 2020.

Hentel’s organization uses Epic as its EHR, and plans to embed the decision tree for radiology CDS into its records system and then use XML logic to get results to clinicians within their workflow.

“It will have substantial workflow impacts,” predicts McEnery. “It will require interaction between EMRs and clinical decision support. There's a lot of information that can interrupt the clinicians’ workflow.”

McEnery offers the following suggestions for making the transition:

  • View it as multidisciplinary project, not just an IT project, because of the potential impact on overall clinical workflow.
  • Organize your processes for success by identifying multidisciplinary clinical leaders to participate in the transition process.
  • Test the communication between systems that will need to interact, specifically the EHR and the CDS.
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