Clinical Decision Support or: How I Learned to Stop Worrying and Love Evidence-based Medicine

“Survival kit contents check. In them you'll find: One .45 caliber automatic; two boxes of ammunition; four days’ concentrated emergency rations; one drug issue containing antibiotics, morphine, vitamin pills, pep pills, sleeping pills, tranquilizer pills; one miniature combination Russian phrase book and Bible; one hundred dollars in rubles; one hundred dollars in gold; nine packs of chewing gum; one issue of prophylactics; three lipsticks; three pair of nylon stockings. Shoot, a fella' could have a pretty good weekend in Vegas with all that stuff.”

—Major T. J. “King” Kong, Dr. Strangelove: or How I learned to stop worrying and love the bomb

In the end it always comes down to survival and money.

Three decades ago cookbook medicine arose from these two. Its adoption today depends on the same.

Appearing initially as practice guidelines, “prescriptive standards of clinical conduct” grew from the hope that the quality of patient care could be improved and its cost reduced if physicians consistently applied the best practices known to medicine.

American practitioners hated the idea immediately.

In my 40 years of medical reporting, I have seen few developments that have so rankled physicians. These “guidelines,” righteously mouthed with squinting eyes and a snarl, were dismissed as totalitarian-like efforts that, if adopted, would subvert clinical freedom. They were, in a word, un-American.

Considering the contempt in which they were held back then, and the periodic waves of dissent lodged against them, it is surprising that evidence-based medicine is still around. But it is. And it is more than just around. It is going to directly impact medicine in general and radiology in particular.

Federal legislators, concerned about the continuingly high cost of healthcare, are supporting its adoption. And, with the ubiquitous spread of electronic health records systems, the tools for implementing evidence-based medicine — as it has come to be called — are in hand.

The use of software that embodies evidence-based rules has been or will be mandated in all three stages of “meaningful use” pertaining to the use of EHRs. And, in a little more than a year, CDS specific to medical imaging will become law as written in the Protecting Access to Medicare Act of 2014.

Much as they did in the past, the best practices baked into imaging-oriented CDS bear the hallmarks of cookbook medicine. Expert panels, convened by the American College of Radiology (ACR), identified these best practices. And those practices are unequivocally prescriptive.

But this CDS differs from the practice guidelines so reviled in the past. Importantly, it does not offer comprehensive instructions about the handling of patients. Rather this software is tightly focused. 

By definition, it looks only at imaging, in fact, only advanced imaging. The CDS of interest to radiology is based on the ACR’s Appropriateness Criteria — evidence-based designed to assist referring physicians and other providers to make appropriate imaging or treatment decisions. 

“By employing these guidelines, providers enhance quality of care and contribute to the most efficacious use of medical imaging,” according to the ACR.

Admittedly, the focus on advanced imaging has an onerous feel. The darkness gathers even more with the realization that physicians don’t have much of a choice about whether to use this software.

Starting January 1, 2017, healthcare providers will be legally compelled to use CDS when ordering advanced imaging exams for Medicare patients. From then on, the Centers for Medicare and Medicaid (CMS) will begin tracking providers. Physicians who don’t use CDS, as they should, will be identified based on two years of performance. Beginning in 2020, outliers will be ordered to obtain “prior authorization for applicable imaging services” for an “appropriate” period.

Simply put, if physicians don’t want the government forcing them to routinely preauthorize every advanced imaging exam they order for their Medicare patients, they must start using CDS within 14 months. 

The government views CDS as a way to cut imaging utilization, an approach that seems at odds with the best interests of radiologists. Yet, the ACR argues that the use of CDS is in the best interest of its members. Why?

Because it “effectively prevents Medicare from adopting call-in prior authorization for imaging utilization management and establishes radiology as a leader in promoting evidence-based imaging care for our patients,” wrote ACR Chair Bibb Allen, Jr., M.D.

Will a connection between CDS adoption and reimbursement, forged by the government and promoted by the ACR, pave the way to radiology’s salvation … perdition … or somewhere in between?

The answer may come down to how well CDS works.

Editor’s note: This is the second 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.