ACR Bulletin

Covering topics relevant to the practice of radiology

Homing in on Quality

Radiologists in rural western North Carolina are strengthening their relationships with local physicians and reducing inappropriate imaging via R-SCAN®.
Jump to Article

By providing free tools like CareSelect® Imaging CDS software, scholarly journal articles, and educational webinars, R-SCAN brings radiologists and referring clinicians together to improve the ordering of imaging exams.

November 15, 2018

For radiologists at Asheville Radiology Associates, 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.

With the passage of 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).

Mission Health and the radiology group had already been evaluating CDS tools to integrate with the system’s 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.


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.

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-SCAN®) came in.

By providing free tools like CareSelect® Imaging 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.

We’d rather be in front of the curve as opposed to behind it.

—Richard S. Arwood, MD


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.

The Asheville radiologists — in close collaboration with the ACR — agreed to take a random sample of patients and then plug image ordering data into the CareSelect CDS tool to find the physicians who had 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.

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 CareSelect 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 AUC documentation that was relevant to a particular case.”


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, senior vice president of innovation for Mission Health System. “We need to transform healthcare. 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.”

Referring 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.”

“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 to speed things up and improve communication between radiologists and the clinicians in the outpatient setting, which we had sort of lost.”

“As CareSelect 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 IR 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.”

Author Amena Hassan  Freelance Writer, ACR Press