Imaging has been under scrutiny, with policymakers touting techniques such as prior authorization and clinical decision support (CDS) as ways to reduce inappropriate exams. But how effective are these techniques, particularly CDS? It's not yet clear, according to a presentation given this week at the AHRA annual meeting in Las Vegas.
"We don't know yet if CDS is a boondoggle or a boon," presenter Liz Quam, executive director of the Center for Diagnostic Imaging's (CDI) Quality Institute, said in a talk on July 19. "We need to work to make it a boon for us."
Why CDS?
At the urging of radiology benefits management (RBMs) firms, President Barack Obama has included proposals to require prior authorization of imaging studies in each of his budgets since his first in 2008. Why? In part because imaging spending in Medicare doubled between 2000 and 2006, rising from $6.9 billion to $14.1 billion, Quam said.
Liz Quam, executive director of CDI Quality Institute.But the numbers don't tell the whole story.
"Lack of understanding of imaging has led to the perception of inappropriate scans," she said. "But across-the-board cuts are an unsustainable cost-saving solution for a lifesaving technology."
Healthcare providers, software developers, and diagnostic imaging vendors have sought a better way to contain inappropriate imaging. Much of that work has been done under the umbrella of the Imaging e-Ordering Coalition, a group that promotes clinical decision support via software rather than prior authorization protocols such as those used by RBMs.
"RBMs have been problematic," Quam told session attendees. "They raise the question of whether this is really how we should be treating patients -- that is, forcing them to wait for care while insurance firms process imaging requests."
Clinical decision-support software is more flexible, according to Quam. She listed some of its benefits:
- Enables real-time decision support
- Provides iterative education for providers
- Reduces patient exposure to unnecessary radiation
- Documents the appropriateness of care
- Drives quality up and costs down
- Reduces rescheduling of scans
- Improves patient flow and clinical efficiencies
- Supports the provider-patient relationship
- Promotes consultation between radiologists and ordering providers
- Helps meet meaningful use requirements
What does CDS software help users to do? Ideally, it allows physicians to recommend the most appropriate course of treatment at the point of the exam order and in real-time. It provides reliable clinical guidance for analyzing a patient's indications and comparing them to evidence-based data, incorporating specialty society guidelines, and documenting the appropriateness off the imaging exam -- which is reassuring not only to the ordering physician, but also to patients, payors, and policymakers, Quam said.
She outlined the cost savings from using CDS software versus a prior authorization model identified by a pilot program in Minnesota, noting that the CDS program saved $168.5 million over three years (2007 to 2009).
"This pilot program found that the point-of-order decision-support system was more efficient than calling an RBM firm, and it had a greater capacity for shared decision-making with patients," she said.
2014 victory
In 2014, supporters of CDS software won a victory in the Protecting Access to Medicare Act (PAMA), which mandated the use of appropriateness criteria in the ordering of advanced imaging exams, Quam said. The legislation has consequences for providers who don't comply.
"Ordering professionals identified as outliers compared to their peers will be subject to prior authorization beginning in January 2020," she said.
Yet there is still work to be done. The appropriate use criteria must be developed or endorsed by national medical societies and be evidence-based, and the U.S. Department of Health and Human Services must issue rules by November of this year that designate the criteria. Approvals of the criteria are expected June 2016. And part of this process includes standardizing payor information, each exam's CDS appropriateness score, and the reason for the exam, Quam said.
To this end, a work group designated to standardize imaging orders has been formed, and CDS representatives include those from National Decision Support (NDSC), RIS and electronic medical record (EMR) vendors, professional and standards associations such as the Radiology Business Management Association and AHRA, and radiology groups such as CDI, Strategic Radiology, and RadNet.
So what's the time frame for this process? The CDS requirement for all advanced imaging goes into effect in January 2017, which means the technology should be tested and usable by October 2016, according to Quam.
"The vision is to develop a seamless set of standards that will guide the process of imaging ordering," Quam concluded.
