Radiologists and their administrators are learning that implementing appropriate use criteria-based clinical decision support (CDS) requires careful planning and execution. Real-world examples of CDS challenges presented at ACR 2017 reinforced the urgency of getting this process started now.
Pending forthcoming CMS regulations expected in either late June or early July, beginning January 1, 2018, referring providers must document that they consulted Medicare-approved appropriate use criteria (AUC) prior to ordering advanced medical imaging (CT, MRI, PET and nuclear medicine exams) for Medicare patients. This Medicare mandate is required by ACR-backed provisions in the 2014 Protecting Access to Medicare Act (PAMA). One way for referring providers to document that they consulted AUC is to enter a physician identifier into a CDS online form when ordering such exams. CMS will issue a final rule for this process, including a list of approved AUCs, in late June or early July.
Brent Savoie, MD, JD, a Vanderbilt University radiologist, warned the audience to prepare to make the upcoming deadlines because CMS and many commercial insurers are committed to making CDS happen.
Bruce Berlanstein, MD, MBA, director of quality and safety at Johns Hopkins Health Care System emphasized the need for buy-in for many quarters of a hospital or health system. CDS needs champions in radiology and front-line physicians as well as a strong relationship with their CDS/AUC and electronic health record vendors, trainers, analysts and consultants.
Berlanstein recommended starting with a pilot program involving many general practitioners before attempting full implementation. CDS systems should be able to incorporate multiple AUCs. For documentation, a unique identifier is required for each CDS consultation and CDS must give ordering physicians an immediate determination of applicability and should include a “not applicable” option on the display. CDS does apply to the emergency department, but emergency procedures are exempted. CDS is not required for inpatient orders and procedures covered by Medicare Part A.
Sarah Reimer, MD, of Aurora Healthcare, an integrated hospital system in Wisconsin, urged planners to read the enabling legislation for the CDS-AUC mandate to avoid later surprises about its requirements. She emphasized detailed planning to anticipate the effect of CDS-AUC at multiple levels of clinical practice and administration. Independent providers should be involved in the configuration of CDS system to assure their buy-in and equipment use.
Planners can expect many changes in the transition for project planning or actual operations. The funding sources shifts from project funding to operations funding. The funding target shifts from implementation and acquisition to supporting the costs of upgrades and system optimization. The project implementation team provides governance before implementation, and CDS itself is the key governing mechanism after it is operational.
Daniel Durand, MD, chairman of radiology and medical director of Life Bridge Health emphasized the need for an easy to understand presentation of how CDS-AUC planning and implementation will proceed. “These programs attempt to assure that orders for advanced medical imaging are the right test for the patient at the right time,” he said. ‘Ultimately, they are designed to discourage inappropriate imaging and reduce its costs.”