CDS for Imaging: A Great Idea Whose Time Has NOT Yet Arrived

Not many pharmacists will call up doctors and question their choice of medication. It’s not hard to make a good case for pharmacists to stay out of the practice of medicine, but it’s tougher when it comes to radiologists who are, after all, physicians licensed to practice medicine. Yet referring physicians choose the imaging exams.

Ideally, they should consult with radiologists to at least keep up with advances in medical imaging — for example, the MR application that does as well or better than CT in evaluating a suspected condition. Or the ultrasound study that provides the same information for less money and less inconvenience to the patient?  

But realistically, neither referring physicians nor radiologists have a lot of extra time. Consults are tough to fit in.

Software that provides clinical decision support (CDS) for making imaging choices sounds like a great idea, if only to make radiology a bigger part of the process behind ordering exams.  America is on course to begin implementing CDS software, at least for advanced imaging studies. The proposed starting date for its use on Medicare patients, as mandated by the U.S. Congress, is Jan. 1, 2017.  But there are a lot of issues that make this start date unrealistic, says Sheila M. Sferrella, chair of the AHRA regulatory affairs committee.

Even a cursory look at the issues surrounding CDS indicates that mandating its use on Medicare patients in less than 14 months is premature. The very foundation for its use is not yet in place.  Congress stated that the appropriateness criteria for imaging exams be chosen by a medical specialty. (The Protecting Access to Medicare Act of 2014 requires that, by Jan. 1, 2017, all referring physicians must “consult with an applicable appropriateness use criteria” prior to ordering certain imaging exams. PAMA also requires the government “to specify applicable appropriate use criteria, developed or endorsed by national professional medical specialty societies or other provider-led entities by Nov. 15, 2015.”

One might conclude that means radiology. And the American College of Radiology has put together such criteria. But so have other medical specialties, including cardiology and family practice.

“There are lots of ‘provider-led entities’ – medical associations and physician associations — that have been developing clinical decision support for medical imaging,” Sferrella said.  

Then there are logistical considerations. Ideally exam orders would be electronically transmitted using a standardized form. But, for the most part, referring physicians prefer to it on a prescription pad or on a form of their own making.

Information technology staff at hospitals and imaging centers must implement CDS-based ordering. And that will take some time. So will the budgeting. Because ACR Select, for example, is licensed, facilities or practices that choose to use it must pay a monthly charge up to $10,000, according to Sferrella.

“You can’t just stick those expenses in your budget in the middle of the year,” she said. “You need at least a 12 to 18 month time frame.”

On Nov. 5, the Centers for Medicare and Medicaid Services announced its decision to delay implementation.

In a statement provided to ITN, the National Decision Support Company (NDSC) explained the cost structure built into its license. “Providers access ACR Select through an annual subscription as part of their EHR (electronic health records system) purchase or directly with NDSC. The subscription is priced consistent with the company’s role as a licensing agent to the market for national standard criteria with minimum subscription well below $10,000 per month.” 

Varying by location and circumstance is who at the hospital or imaging center will ensure that the referring physician has used appropriateness criteria. Ideally this would be done by radiology staff. But order forms are processed at some hospitals by billing clerks who may be minimally familiar with radiology. And, when orders are found lacking, how is the problem resolved? Who resolves it? Just dealing with these issues could require an FTE or two, she said.

 And, who keeps track of how well referring physicians are using CDS? The Congressional mandate makes radiology responsible for tracking the use of appropriateness criteria by referring physicians and reporting this use to CMS. Sferrella likens the requirement to filling out report cards.

“The imaging provider is going to have to tell CMS where these physicians are on an appropriateness scale of CDS use,” she said.

Not only does the Congressional mandate put radiologists in the position of being a CMS informant but it also puts them at risk of not being paid, if referring physicians don’t use the appropriateness criteria.

The mandate only applies to Medicare patients. But there is no way radiology departments can currently limit its use this way. “The technologist does not get patient insurance information, so from our perspective, we have to use appropriateness criteria on all patients,” Sferrella said.

A workaround for some of these problems might be for hospital administrators to dictate policy regarding the use of appropriateness criteria. But what about imaging centers? Radiology staff at these centers could alienate referring physicians, if they question how well they are using appropriateness criteria.

The safest course right now, according to Sferrella, is to buy some time to figure out the issues that stand in the way of the successful use of CDS. AHRA and other organizations are asking CMS to delay implementation 12 to 18 months. 

Editor’s note: This article was revised on Nov. 10, 2015. This is the fourth blog in a series of four by industry consultant Greg Freiherr on Clinical Decision Support. The first, “How Clinical Decision Support Can Help Radiologists,” can be found here. The second, "Clinical Decision Support or: How I Learned to Stop Worrying and Love Evidence-based," can be found here. The third, Does Clinical Decision Support Software Work? can be found here.