March 19, 2019

Implementing CDS: A Q&A With Ryan K. Lee, MD, MBA

In this Physician Spotlight, we talk with Ryan K. Lee, MD, MBA, Vice Chair of Quality and Safety, Magnetic Resonance Medical Director and Section Chief of Neuroradiology within the Einstein Healthcare Network, about looming Protecting Access to Medicare Act (PAMA) legislation and five actionable steps radiologists can take to help their organizations implement clinical decision support (CDS).

What do radiologists need to know about PAMA and the approaching CDS mandate?
First of all, radiologists need to know that the PAMA mandates are real and the deadlines are rapidly approaching. Starting Jan. 1, 2020, PAMA requires referring providers to consult appropriate use criteria (AUC) prior to ordering advanced diagnostic imaging services — CT, MR, Nuclear Medicine and PET — for Medicare patients. An AUC consult must be documented via a CMS-qualified clinical decision support mechanism (qCDSM).

When will radiologists be impacted financially if that AUC consultation does not happen?
The AUC consultation requirement will start with a 12-month educational and operations testing period, which runs Jan. 1, 2020 – Dec. 31, 2020. During the period, professionals must participate in the program and make an effort to use the AUC claims process, but payment is not at risk if there are shortcomings or mistakes. Beginning Jan. 1, 2021, rendering professionals’ technical and professional component reimbursement could be denied for failure to verify that the AUC process was satisfactorily used.

Do referring providers have any skin in the game when it comes to being denied reimbursements?
Ironically enough, the ordering clinician does not have any penalty. It's solely on the radiologist and whoever owns the imaging scanner. That’s the paradox with this mandate: Only the “rendering providers” will potentially be denied reimbursement for a scan without a documented AUC consult. So, the onus is squarely on radiologists to take a leadership role in ensuring CDS is implemented and the AUC consultation process is operationalized in their environment well before the 2021 deadline — when payments will be impacted. Not only do we have the knowledge and expertise about appropriate imaging, we have a financial incentive to ensure the right scans are ordered, with the proper coding of consult via CDS, so that we can be paid. According to CMS, eventually providers who routinely order inappropriate exams could be required to obtain preauthorization for a study.

Beyond the financial implications, why else should radiologists take a leadership role in implementing CDS in their practices?
Increasingly, it is imperative for radiologists to demonstrate their value in patient care and their roles in image ordering using the most appropriate criteria for the patient’s condition. One of the areas where we add value (besides generating a radiological report) is ensuring that the patient is obtaining the correct study for a given problem. So shepherding CDS implementation is one way that we can add value to patient care and make it easier for our referring colleagues to order the right study. Until recently, radiology’s AUC has been sitting in huge binders packed with paper that were difficult to access at the point of care. It is now much more accessible to the clinician through CDS and the EMR, so it’s a convenient way to provide value for the clinician.

What are some actions radiologists can take now to get started implementing CDS in their own practices?
Based on
our experience implementing CDS at Einstein, here are five key steps that I recommend to every radiology department or practice:

  1. Get started now. It’s imperative to make the best use of the operations and testing year to ensure everything is in place and running smoothly before the reimbursement penalty kicks in. The more lead time, the better. As good as many of the CDS mechanisms are (for example, CareSelect Imaging™) they really need to be tailored to a specific network. Every network is different, and you will want to test it out and make sure that your ordering clinicians are happy with how it's being used and that the indications fit properly to the local ordering culture. All this requires some time to get working smoothly. The ACR Radiology Support, Communication and Alignment Network (R-SCAN™) is a great introduction to CDS, because it allows you to partner with clinicians and get your feet wet.

  2. Raise awareness about what’s coming and when. Most referring providers, and even radiologists, are not familiar with the PAMA mandate or when it's happening. In fact, I just got back from a speaking engagement where I presented to a group of practitioners, ER physicians, neurologists, surgeons and the like. I asked them, "Do you know about the mandate for CDS?" Similar to what I have seen in previous years, there were only two people out of a hundred who put up their hands. In general, there needs to be increased awareness for the CDS legislation.

  3. Gain buy-in from stakeholders. Before embarking on an initiative to implement CDS in your practice, sit down with health system administrators and clinical leaders in your network to gather their input. Forge collaborative partnerships with department heads in clinical areas like the emergency department, internal medicine and pediatrics. They will be the primary users of the CDS system, so you want to ensure it fits their workflow and adds value to their patient care process — before you get too far down the implementation path.

  4. Look for opportunities for continuous education and engagement. Once you’ve deployed CDS in your organization, develop a plan for ongoing communication, training and participation. Attend clinical staff meetings and present lectures to demonstrate what CDS is and how to use it. Send regular email updates about progress and new capabilities. Develop handout materials and educational videos to get clinicians up to speed about using CDS in your institution.

  5. Solicit feedback every step of the way. To boost the impact of CDS and engender maximum participation in consulting AUC, find ongoing ways to gain input from users and make continuous improvements. Consider email and online surveys, and return to their staff meetings regularly to take the pulse of clinicians and leaders.
What is one thing you wish you had known about CDS before you got started?
I wish we had engaged with our clinical leaders even earlier in the process. Before CareSelect Imaging, we had a false start with another CDS tool that didn’t fit our needs and workflow. With more consultation and partnership with clinical users early on, we would have had a smoother start and faster success with CDS.

What is one thing that is important for every radiologist to know about CDS right now?
Every radiologist should understand the mandates of CDS and the implementation deadlines, because it is our responsibility to make ordering providers aware. Unfortunately, a lot of radiologists don't know enough about it to take a leadership role. As radiologists, we should all be much more proactive, because the clinical doctors are relying on us in many ways. When it comes down to it, these are our radiology studies, so we should own CDS and be able to proactively provide critical information to referrers.

Ryan K. Lee, MD, MBA

Ryan K. Lee, MD, MBA, is Clinical Associate Professor at the Sydney Kimmel College at Thomas Jefferson University. He is the Section Chief of Neuroradiology in the Einstein Healthcare Network and serves as Vice Chair of Quality and Safety and Magnetic Resonance Medical Director in the Department of Radiology. His areas of expertise include radiation management in imaging, radiology CDS, MRI safety and increasingly, artificial intelligence. With practical experience in the implementation of radiology CDS, he has given numerous lectures regarding its benefits. He is also well versed in the economics of health care, including within the realm of radiology, and serves as the Alternate RUC Advisor for the American Society of Neuroradiology.

Dr. Lee is a member of the ACR Appropriateness Criteria® Neurological Imaging Subcommittee, ACR MACRA committee, ACR Economics Subcommittee on Neuroradiology, and the Quality and Safety Committee of the ACR Commission on General, Small, Emergency and/or Rural Practice.