Clinical Decision Support for Advanced Imaging
Clinical decision support (CDS) is software that takes a national vetted set of criteria and utilizes them to transparently and reliably give clinicians guidance to order the right treatment for the patient In the case of advanced imaging, it’s the American College of Radiology’s (ACR) appropriateness criteria (AC). CDS provides this guidance to help clinicians eliminate inefficiencies, such as having a patient show up only to realize the wrong study was ordered.
In my other career, I am my sons’ Little League coach. Now that they are 10 years old, the coaches have introduced plays – what to do in this situation, what to do in that situation. In a sense, we’ve given them a set of algorithms. Whether at the Little League level or in the big leagues, the basic plays are the same. Imagine, for a moment, that instead of teaching them these plays, I just sent them out on the field with no guidance and said “play ball.” That’s exactly what we are doing today with clinicians. How can we expect clinicians to know every nuance of the ACR criteria? How can a clinician be expected to know the subtle differences between ordering a magnetic resonance image (MRI) of the neck vs a CAT scan of the neck? The answer is we can’t expect that; it’s not their job. That’s my job as the radiologist. And, that is exactly what the ACR has done with their AC. There are subcommittees for each subspecialty that have convened and agreed on what are appropriate exams for given indications.
In order to improve the quality of medical imaging services, Einstein Healthcare Network (EHN) began the process of implementing CDS for advanced imaging services in June. The solution is integrated into our Cerner workflow and provides evidence-based, peer-authored content that is compliant with future legislation requiring the use of decision support. The Protecting Access to Medicare Act of 2014 requires that physicians who order advanced diagnostic imaging exams must consult government-approved CDS software.
There are a few interesting additional benefits of decision support. The decision-making process can be documented in the EHR. That means when the evidence recommends against performing a test, it can be noted and used to provide a shield against the need to practice defensive medicine. Secondly, we can eliminate the need to have imaging studies preapproved by a Radiology Benefits Manager. This can save everyone time, effort and money. And, it creates a more collaborative relationship between providers and payers.
The best known case study about the use of decision support for ordering diagnostic images is from Minnesota. Back in 2006, the Institute of Clinical Systems Improvement (ICSI) projected that, by 2012, the Minnesota imaging utilization rate would rise from just over 40 studies per 1000 members to almost 56 studies per 1000 members. Instead, by implementing CDS, this growth in the rate was largely slowed. This has translated into a savings of over $200 million to payers and patients since the beginning of the intervention.
As we continue to move further away from a fee-for-service model to a value-based model, it is more important now than ever to minimize the inappropriate use of advanced imaging studies. We want our department, radiology, to take the lead in that respect. Over the years, we have had decreasing interaction with our colleagues, mostly due to technology. Clinicians can see their scans pretty much anywhere, and they don’t come down to the department as much as they did 20 years ago. Clinicians, as a result, are ordering studies with less guidance than they previously did. CDS brings back the guidance that had been lost. Also, importantly, it provides the potential for increased interaction with the radiologist by providing a mechanism for consultation in problematic cases.