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Dr. Bryon DickersonTaking the path less traveled almost always leads to a few twists and turns. For radiologists at Asheville Radiology Associates in Asheville, N.C., paving a new route means success in educating their referring clinicians about appropriate image ordering. However, the group faces a unique challenge in doing so: Their referring providers are distributed across a wide geographical area in rural western North Carolina.

For years, the group’s radiologists had done their best to familiarize their referrers with image ordering best practices. But, because the independent community hospital system they serve, Mission Health, comprises six hospitals and various outpatient and surgery centers distributed across a wide geographical area, face-to-face contact was challenging.

With the passage of the Protecting Access to Medicare Act of 2014 (PAMA), however, the leadership of Asheville Radiology perceived that their role as consultants was about to get a boost. PAMA requires referring clinicians to order advanced imaging procedures for Medicare patients through a clinical decision support (CDS) tool that is based on appropriate use criteria (AUC).

As luck would have it, Mission Health and the radiology group had already been evaluating CDS tools to integrate with the system’s electronic medical record (EMR). Given the geographic challenges involved in keeping their referring providers abreast of periodic changes in image ordering guidelines, the group’s leadership saw an opportunity to demonstrate their value to the health system.

A Consultative Approach

Bryon A. Dickerson, MD, president and executive medical director of Asheville Radiology Associates, and his radiologist colleagues were already champions of using CDS to automate and improve imaging appropriateness across a far-flung rural area. But they quickly realized that an algorithm couldn’t determine every finding.

As a result, the radiologists knew they would have to make themselves more available to ordering physicians as a consultative resource. But how would the group manage the coming demand for their time?

Beyond implementing CDS and simply increasing their consultation time, it soon became clear that another way to enhance efficiency would be for the radiologists to reposition themselves as educators. That’s where the ACR’s Radiology Support, Communication and Alignment Network (R-SCANTM) came in.

By providing free tools like the ACR SelectTM CDS software, scholarly journal articles, and educational webinars, R-SCAN brings radiologists and referring clinicians together to improve the ordering of imaging exams. The R-SCAN action plan is based on a growing list of Choosing Wisely® imaging topics and is aimed at promoting selection of the best imaging exam based on evidence-based AUC.

Dickerson immediately saw R-SCAN as a powerful tool to introduce both bringing CDS into their workflow and engaging their referring physicians in a dialogue. “We realized that R-SCAN would help us move forward toward successful CDS implementation. To encourage success of the program, we identified physicians who are key stakeholders and leaders in their respective service lines,” Dickerson notes.

An Educational Collaboration

From the outset, health system administrators showed an interest in CDS that was not initially mirrored by the referring clinicians. “Physicians often feel that IT systems and EMRs are designed for billing purposes rather than for patient care and communication among doctors,” Dickerson says.

“One of the referring doctors showed me his staff’s workflow and said that while he wanted to order the most correct imaging test, it would have to be done with the fewest amount of clicks,” he adds. “So we really tried to put ourselves in the referring doctor’s shoes to see how they would find R-SCAN most useful.”

To meet their referring clinicians’ request, the practice leaders realized their particular situation merited a novel approach to the Choosing Wisely topics. “The group really didn’t want to plug our referring doctors into the standard Choosing Wisely pathways that were outlined in R-SCAN,” Dickerson says. “We felt that if we were going to take a substantial amount of time engaging a referring clinician, we wanted it to be meaningful and useful specifically to them.”

To ensure the encounters made the most efficient use of everyone’s time, the Asheville radiologists — in close collaboration with the ACR — agreed to take a random sample of patients and then plug image ordering data into R-SCAN’s ACR Select CDS tool to find the physicians who were considered outliers (in terms of ordering patterns that reflected unnecessary imaging).

Armed with this information, the radiology group reached out to a small number of referring physicians, re-established relationships with their staffs, and began scheduling one-on-one appointments with referring providers to educate them about appropriate imaging guidelines. The practice found their rural providers receptive to this educational approach.

James Murray, director of quality and safety at Asheville Radiology Associates, notes that since embarking on the R-SCAN initiative, the group has endeavored to balance education with efficiency. “We present the provider with their ACR Select results, and we review some specific cases with them,” Murray explains. “Then we address any questions they might have and follow up by sharing the appropriate use criteria documentation that was relevant to a particular case.”

(To learn more about Asheville Radiology's quality improvement program, including implementation of R-SCAN, read the accompanying article.)

A Warm Reception

The administrators of Mission Health took to R-SCAN from the beginning. “When Dr. Dickerson first came to me about R-SCAN, I was very enthusiastic,” explains Marc B. Westle, DO, FACP, senior vice president of innovation for Mission Health System. “We need to transform health care. It’s not one single thing that needs to change, but a number of things. But how do we do it? Dr. Dickerson had an excellent idea for educating physicians about how to order appropriate imaging tests in advance of when they’re actually ordering them.”

Dr. Norris CriglerReferring clinicians within Mission Health agree with Westle’s assessment. “Engaging in this up front is going to help us better prepare for when CDS is required for Medicare reimbursement,” says Richard S. Arwood, MD, hospitalist at Mission Health. “We’d rather be in front of the curve as opposed to behind it.”

According to Arwood, the R-SCAN initiative was as valuable to the referring clinicians as it was to the radiologists. “It was very clear from the start that R-SCAN would be good for our patients and right for the health system,” he says. “There’s no other way to do it than to jump in.”

“We’d had so many delays with prior authorization requests, because we may not have been aware of some of Medicare’s standards for ordering certain tests,” says Ernesto E. De La Torre II, MD, family medicine physician at Medical Associates of Transylvania. “But Dr. Dickerson proposed R-SCAN as a way to speed things up and improve communication between radiologists and the clinicians in the outpatient setting, which we had sort of lost.”

The collaborators are currently in the post-educational intervention evaluation phase of the program. As the radiologists prepare to gauge if the educational efforts succeeded in improving provider image-ordering patterns, they are optimistic.

“As ACR Select is embedded into our EMRs, we’ll have to make sure the process is streamlined and not especially onerous for our physicians,” explains Norris W. Crigler Jr., MD, a 35-year veteran interventional radiologist and the practice’s regional director of community hospitals in the outlying regions of Asheville. “It’s just easier if we head that off by educating referring physicians first and help them form an idea of what they’ll be working toward in the near future. Hopefully, they’ll become strong advocates of CDS.”

A Look Ahead

Dickerson is appealing to physician leaders at Mission Health to get the word out to their staffs regarding the importance of the upcoming implementation of CDS into their EMRs. “My main concern is that this can’t be a top-down approach,” he explains. “I’ve encouraged all 15 of our medical directors to begin engaging and developing relationships with others to get ahead of the curve. We want the educational and training process to be on a grassroots level.”

While CMS has given health systems the gift of time — pushing back the original PAMA CDS deadline — Dickerson feels it is crucial to speed up the health system’s CDS implementation process to ensure all of the steps are in place well in advance of the start date. Toward that end, their efforts include using R-SCAN more widely to educate referring physicians, while also having Mission Health’s IT department on hand and available to integrate the new system into physicians’ workflows.

“Most importantly, we shouldn’t rest on our laurels,” Dickerson says. “We should really use this extra time to engage our referring physicians in a meaningful way, so that they can feel comfortable when CDS is finally implemented within our system.”

De La Torre recognizes the special relationship he now shares with his radiologist colleagues after participating in R-SCAN. “R-SCAN has helped me realize that radiologists are not just people sitting in a room at the hospital somewhere reading CT scans. They are a resource. They are consultants with vast knowledge bringing something to the table to help me care for my patients.”

R-SCAN participants have several options for defining their own R-SCAN topic to meet unique practice needs. There are several approaches to carrying out a practice-defined topic. Some of these, such as combining several topics from the Choosing Wisely list, may be especially desirable for small and rural practices that have limited volume for any one imaging exam. Please see these instructions for more details.

Next Steps

•   Establish and maintain relationships with hospital and physician leaders in order to gain support when implementing R-SCAN.

•   Become familiar with R-SCAN first and then demonstrate to clinicians its benefits for reducing inappropriate imaging tests for patients, how it saves time for the health system, and its role in reducing ordering delays.

•   Plan ahead for implementing CDS into your workflow so IT departments and other players can effectively align and work with your practice or hospital.

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                                                  Amena Hassan is a freelance writer