Use of clinical decision support set to start for imaging tests

Radiology practices may be left holding the bag as the federal government rolls out a plan to require the use of clinical decision support in ordering studies.

The use of clinical decision support to order imaging studies for Medicare patients for several common procedures is scheduled to begin on January 1, but much remains unknown about how the program will operate in practice, according to experts presenting at the recent annual meeting of the Society for Imaging Informatics in Medicine.

The program is mandated under the "Protecting Access to Medicare Act" (PAMA) bill, passed in 2014 in an effort to rein in spending on radiological exams. Beginning January 1, providers who order eight types of advanced imaging studies for outpatients will be required to prove that they have consulted an approved appropriate use criteria (AUC) evidence-based knowledge base at the time an order is initiated for the imaging provider to get reimbursed.

There will be a one-year grace period during which providers won’t be penalized, but then radiologists’ payments could be at risk if physicians ordering one of the eight types of radiological studies don’t include evidence that they consulted decision support and include appropriate codes on their orders.

There are challenges, says Richard Bruce, MD, medical director of radiology informatics at the University of Wisconsin, Madison. At the SIIM conference, Bruce said the implementation of the program has been delayed three years to give the industry time to ramp up needed technology. “Providers and radiology practices were not prepared for this,” he noted.

However, it’s not certain that all the pieces are in place for the program. For example, there may not be a uniform way for clinicians ordering the radiological exams to access the clinical decision support they need to see before making a decision—will it come through the electronic health records system they’re using, or will they need to go to another information source, such as a portal, to get clinical guidance?

Clinicians will be able to override guidance, but eventually, the top 5 percent of clinicians whose orders conflict with AUCs will be deemed outliers and will eventually be required to gain third-party authorization to order imaging, says Adam E. Flanders, MD, co-director of neuroradiology, ENT radiology at Jefferson University.

As a large proportion of many radiology practices provide services for Medicare patients, there is potential for substantial financial risk for many radiology practices if CDS is not implemented or not implemented well. Radiology practices can “expect to get denials within a year,” Flanders said.

Many institutions have either implemented CDS already or are in the process to do so to meet regulatory compliance.

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Weill Cornell Medical Center has been using clinical decision support for about 10 years, and participated in a Medicare imaging demonstration project in 2014, said Keith D. Hentel, MD, chief of ER and musculoskeletal imaging at NY Presbyterian Hospital, Weill Cornell Medical Center, as well as vice chairman of radiology at Weill Cornell Medicine.

Organizations that don’t have CDS in place for this set of Medicare-reimbursed procedures have many decisions to make, Hentel said. CDS systems may need to stand separate from imaging systems, because they’ll be faster to implement that way.

Further, providers will need to make decisions on which appropriate use criteria they’ll use—about 20 entities have been qualified by the Centers for Medicare and Medicaid Services to offer evidence-based criteria, and there are about a dozen qualified decision support mechanisms from which providers can choose. The complicated process also will involve medical coders and billing staff, and they should be involved from the beginning, he advises.

“There is going to be pushback” from physicians who have to use the CDS systems to justify imaging procedures, Hentel warned. “Organizations need to think about what else you can do to encourage acceptance.”

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