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
ACR guidelines are developed and kept updated through the work of about 100 member specialists and by a dedicated staff within the organization, so it is important to know how frequently a CDS vendor incorporates these changes and additions and the manner by which it notifies its customers. This can be especially important if a customer hospital has significantly customized the rules for a guideline that would be impacted. Beyond this, workflow integration, ease of use, speed of delivery, customization, flexibility, and analytics capabilities are the key factors to evaluate.
Integration: A radiology CDS system must be integrated with the CPOE system to be efficient. However, the better it can be integrated with the EMR, the better it will be for users. If pertinent patient data from the EMR can automatically and seamlessly populate the fields of the radiology CDS, workflow will not be impeded by the need to re-enter necessary patient data that a physician has already entered into the EMR.
Simplicity, ease of use and efficient workflow: In addition to an easy-to-visualize and use graphical user interface, the content should be context-specific, concise, unambiguous and easy to select. Complexity of options and dropdown menus, numerous scroll bars, and fields to fill will be detrimental to use. The decision-tree chain should be designed to minimize mouse-clicks, instead providing one-click options that rapidly deliver an appropriateness score. Access to explanatory information and published studies should be available through links, but not a required part of the process.
According to Steve Herman, M.D., a thoracic radiologist and chief medical officer of MedCurrent (which offers the OrderRight clinical decision support system), the last thing a busy doctor wants would be bombardment with numerous options, check boxes, and extra information. “Ordering physicians must find the system efficient and easy to use. They cannot be presented with screens full of information that will slow them down. The last thing that a CIO wants to contend with is doctors who hate the system, because ultimately they are going to be required to use it,” he says.
He also advises that in situations when other exams are recommended instead of the one being ordered, a user should be able to immediately switch to ordering a different exam without having to start all over. “A successful CDS system needs to have the ‘intelligence’ to switch gears midstream quickly without impeding workflow. It needs to be perceived as an aid to provide relevant clinical support to a physician, not be a hindrance,” he says.
Steve Herman, M.D.
Among his recommendations for a successful system are:
Speed: The faster the system works the better. System performance is of critical importance to user acceptance. Even a few-second delay can give physicians the perception that their workflow is being hampered.
Flexibility: The ability to change an order for an exam midstream is one example of flexibility. The other is the ability to override a negative recommendation and to continue to order the desired exam. Some hospitals intervene with a requirement that the ordering physician must consult with a radiologist to continue to place the order. This may be very appropriate for certain types of exams and clinical situations. However, such interventions might be best only after the CDS system has been in use for a number of months, after there has been a period of time of analysis of “outlier” orders and the reasons for them.
Customization: The ability to easily customize a CDS system, both with respect to authorizing specific exam categories and also to modify the ACR guidelines, is a necessity. Dr. Herman says that virtually every hospital executive he has talked with has said that while the ACR appropriateness criteria is excellent, it is not 100-percent applicable to their hospital. “The last thing that a CIO in a hospital is going to want to do is be boxed into a set of rules that doesn’t work for them. Hospitals also need the flexibility to make modifications quickly and easily, without needing to ask the vendor to do this; although when selecting a vendor, it’s important to make sure that that sort of support can be immediately offered as well,” Dr. Herman says. As an example, he cites a hypothetical case in which a MRI exam had a score of 8 and an ultrasound exam had a score of 7. If getting a MRI was difficult in the middle of the night, for example, and the clinical situation for the ultrasound would not compromise the patient, it might be more appropriate to tweak the system and give the ultrasound exam a higher score.
Analytics: A CDS system should have a strong analytics component, with the ability to be easily customized as well. Constant monitoring not only shows who is using the system and how well they are adhering to appropriateness criteria, but also identifies areas where modifications may be needed and areas where better guidelines should be developed.
PLANNING FOR IMPLEMENTATION OF A RADIOLOGY CDS
Like any new technology, thoughtful, comprehensive planning is the key to successful adoption. The main objectives are to get physicians to incorporate decision-support technology into clinical routines and to follow the advice they receive.
Gradual implementation of the system may be the easiest route, whether determined by the most frequent exams ordered, by type of specialty, or by geographic entity such as an outpatient clinic, or by a combination thereof. Identifying champions and determining who within a system would be the best pioneering adopters is important. A pilot group of users needs to receive tangible benefit from use of the system and show positive measurable results. Successful adoption is as much a factor of strong leadership and a culture to “do the right thing” as it is the functionality of the system.
Radiology needs to be involved from the outset. First, a senior radiologic technologist or a department manager needs to perform a comprehensive procedure mapping exercise with respect to names of an exam. If the name of a procedure used by a hospital differs from the name in the CDS system, the name in the CDS system needs to be changed to conform. This typically takes a day or two.
The implementation of a radiology CDS should be perceived as a way to restore consultations by radiologists with physicians that have predominantly disappeared with the accessibility to PACS. The hospital’s radiologists need to buy into this, and they need to be ready to answer questions by ordering physicians when a call is placed to the department. There are obviously numerous ways to plan this but the process should be defined and in place before the CDS goes live.
What should be monitored and the frequency of monitoring should also be determined in advance. Feedback needs to be defined. A standard process and protocol for inquiries about “outlier” orders should also be established and conveyed in advance to users. “Outlier” orders may be indicative of a physician who needs better information and a friendly consultation by a radiologist. Or they may represent the exception to the rule. Outlier orders also may identify gaps in guidelines that need to be addressed.
Managers also need to plan how, to whom, and with what frequency reports are ordered. Users need to be kept informed. Doctors by specialty, department, and individual should be kept informed with respect to overall performance and comparison with peers. Compliance, after all, is a factor of objective feedback and peer pressure.
“Launching a CDS system well in advance of the federal requirement of 2017 means that there is much less pressure for both ordering physicians and the hospital. With the right analytics and feedback loop in place, the better and more smoothly it will work when it becomes mandatory,” Dr. Herman explains.
The other benefits: cost-savings to patients, payers and the U.S. economy by eliminating inappropriate and clinically useless exams. There will be enhanced quality service to patients by minimizing physician misjudgment with respect to the exam they are ordering and also by convincing patients who may demand a specific procedure that expert advise may show they are wrong. There will be enhancement of patient safety, especially if a radiation-emitting procedure can be eliminated or substituted with an equally appropriate non-ionizing radiation MRI or ultrasound exam.
What is the risk of a hospital implementing a CDS system in advance of federal requirements and facing the risk of needing to replace it if not ultimately approved by CMS?
Every well-established commercial CDS vendor using ACR Appropriateness Criteria evidence-based guidelines as the foundation of their products or who have licensed ACRSelect software plans to comply with the rules that CMS establishes to vet and approve CDS systems. CMS media spokesman Donald McLeod advises that the agency was still very much in early stages of planning as of October 2014. No office has been formally established yet within CMS to answer inquiries or offer advice. However, it seems highly unlikely that CMS would not adopt the ACR guidelines which cover hundreds of clinical conditions and have been in widespread daily use for over 20 years. The ACR, which works closely with the American College of Cardiology (ACC), the American Society of Radiation Oncology (ASTRO) and other professional organizations that use specialized imaging, has expanded its guidelines-related staff and has been meeting regularly with CMS.
So—is it time to act? If vendor feedback is indicative, a lot of CIOs think so.
Cynthia E. Keen is a freelance writer based in Sanibel Island, Fla. She has been writing about radiology clinical decision support technology since it was first commercially introduced, and has spent more than two decades covering healthcare IT.