As value-based medicine takes hold in the paradigm shift from fee-for-service to accountable care, the role of the hospital radiology department is expected to shift from being a profit center to a pivotal center that drives cost-savings. Imaging’s forté is to provide rapid diagnoses of suspected clinical conditions and to enable caregivers who depend upon radiology exams to function better and more efficiently.
But the use of diagnostic imaging has an Achilles’ heel if a physician doesn’t order the most appropriate exam for a desired diagnosis. Regrettably, there has been little incentive to mandate this. While the radiology profession has developed evidence-based guidelines through 20-plus years of continuous work by the American College of Radiology (ACR), it’s not been hospital culture—nor has there been any financial reason—for radiologists and radiology departments to intervene when exam-ordering mistakes are made by well-intentioned doctors. Until recent years, the clinicians and staff of radiology departments had no easy access to appropriateness guidelines, and often patients’ files themselves, to be able to determine this.
The use of electronic medical records (EMRs) has eliminated the barrier to review a patient’s file. Computerized physician order entry (CPOE) systems integrated with EMRs have made the process of ordering imaging exams efficient. Radiology clinical decision support (CDS) systems integrated with both provide a workflow-integrated, point-of-care evaluation of the appropriateness of the exam being ordered for a patient’s clinical indications, along with recommendations of more suitable or alternative exams. Commercial CDS systems and electronic medical record CDS modules deliver an appropriateness score based on the ACR Appropriateness Criteria guidelines or individual preferences of the hospital itself.
Right now, a very small percentage of U.S. hospitals use radiology CDS technology; but this will change dramatically as of Jan. 1, 2017, thanks to the passage of the Protecting Access to Medicare Act of 2014. Any healthcare provider ordering an advanced imaging exam—specifically computerized tomography (CT), magnetic resonance imaging (MRI), nuclear medicine and positron emission tomography (PET) will be required to consult appropriateness criteria approved by the Centers for Medicare and Medicaid Services (CMS). Use of appropriateness criteria will be mandated by law, and based on input to CMS by professional medical organizations (presumably the ACR and potentially other physician organizations). Reimbursement for advanced imaging exams performed for Medicare/Medicaid patients will be made only if appropriateness criteria are consulted and verified. Smart money is betting that private insurance companies and other payers will follow suit.
It’s not a moment too soon. An estimated 20 percent or more of CT scans are duplicative or ordered inappropriately each year, according to numerous studies published in peer review journals.
Early adopter hospitals of EMRs and CPOEs that have either developed their own proprietary CDS systems or purchased commercial ones have documented impressive results in exam reduction. This intelligent software technology is an effective gatekeeper; but it’s not plug-and-play, and it can be gamed by its users.
So what’s a CIO, COO and CMO to do? Those employed by hospitals that are heading toward accountable care would do well to reap the cost-savings benefits that even a partially implemented radiology CDS system can provide. Early adoption would enable physicians to become comfortable with this technology, easing the pressures associated with mandatory usage. Through usage, a CDS system can be modified to fit the exact needs of their specific hospital or hospital enterprise while preparing to meet the federal requirements.
Just like any new healthcare IT technology, physicians are not likely to embrace a radiology CDS system with open arms. Similar to speech recognition dictation systems, there may be far more resistance than acceptance. A machine is going to judge the wisdom and recommendations of a physician? Although a soon-to-be-mandatory fact of life when practicing medicine, resistance will need to be overcome through cultural change starting with top management and proof through practice that the system will be of clinical value rather than another bureaucratic hindrance.
Most commercial radiology CDS systems today have licensed ACR Select software from the National Decision Support Company, Andover, Mass., which itself has entered a licensing agreement from the ACR. However, CDS systems—like radiology information systems (RIS) and picture archiving and communication systems (PACS)—differentiate themselves in features and functionality.
Should a hospital use the free ACR Appropriateness Criteria and develop its own radiology CDS system? Such an initiative was undertaken by early adopters, most notably Boston’s Brigham & Women’s Hospital in 1998; but with today’s selection of commercially available products, why even consider this?
A savvy CIO would do well to establish a small multidisciplinary team to evaluate the offerings. A good mix would include several physician technology evangelists from different clinical departments, an emergency physician, a radiologist, a radiology IT manager, and a healthcare IT generalist. The team should also be assigned to evaluate the best ways that a radiology CDS system could be utilized with the highest level of success, the greatest potential to achieve the greatest positive impacts, all in the context of available training and deployment resources.
FACTORS TO CONSIDER WHEN EVALUATING CDS SYSTEMS