What Can Clinical Decision Support Do for Your Practice?
CDS systems can serve as automated, instant prior approvals.
Starting Jan. 1, 2020, the Protecting Access to Medicare Act (PAMA) will require referring providers to consult Appropriate Use Criteria (AUC) prior to ordering advanced diagnostic imaging services (including CT, MR, nuclear medicine exams, and PET scans) for Medicare patients. Providers can access imaging AUC via stand-alone electronic clinical decision support (CDS) systems or software embedded in a physician’s EHR.
The ACR and the National Decision Support Company (NDSC) have developed CareSelect Imaging®, which uses the ACR Appropriateness Criteria® (AC) to guide providers ordering imaging for patients. Not only does such a system aid providers in selecting the correct care path for patients, but some practices have worked with their payers to use CDS in place of prior authorization by radiology benefit managers (RBMs).
“We are providing feedback to the provider, as if they were consulting a radiology expert in real time,” says Robert Cooke, vice president of marketing and strategy at NDSC, pointing out that the ACR ACs are created by panels of subject-specific experts.
Such a system, Cooke says, reduces the number of inappropriate images ordered, helps providers meet quality goals based on utilization, and can even enhance the patient’s experience, yielding better satisfaction scores.
Molly Craven, DO, has seen these benefits first-hand while using CareSelect Imaging in her practice at Brookside Family Medicine in Traverse City, Mich., for three years. “I’m not always certain that I’m ordering the correct study, especially when it comes to imaging that may require one or more types of contrast,” says Craven. “During a busy workday, I would have to pick up the phone and speak to one or more radiology employees, before ultimately interrupting a radiologist to discuss my question regarding study type.”
Craven notes that as soon she became comfortable navigating the clinical scenario and indication sections in CareSelect Imaging, it was not difficult to obtain a clear answer about which studies would yield the information she and the patient were seeking.
CareSelect Imaging also provides caregivers the evidence behind the imaging recommendations. “I am quite confident that when I need to request a prior authorization, I have good data to back up my choice of imaging,” says Craven.
Consider this scenario: a patient who self-reports with non-traumatic low-back pain without neurologic symptoms and asks for an unnecessary MR. When the provider consults CareSelect Imaging, the evidence reveals that a first round of treatments should be used before ordering imaging. Sharing these evidence-based guidelines may help patients make informed decisions about their care and can support the referring provider in ordering the best study for a given clinical indication.
According to Cooke, a CDS system also saves providers a great deal of administrative time and expense. Many RBMs require providers to submit information via fax forms or telephone calls. Challenges to a denial also require significant administrative resources.
“A CDS system automatically extracts the correct data, formats it, and submits it,” says Cooke. “We can have a complete solution to provide automated prior authorization or to at least automate the request from the provider organization so that they don’t have to navigate that complex and arcane process.”
The notion of working within the RBM system is a crucial point because more than 90 million Americans are currently insured by a payer that requires prior authorization through an RBM.1 With a transparent, evidence-based CDS system, one that is accepted by an RBM or payer, that prior authorization could be nearly instantaneous. The provider and the patient could receive authorization in minutes, rather than days.
The adoption of CDS now enables provider organizations to confidently demonstrate to their payers that they have a mechanism in place for delivering transparent, evidence-based AUC directly into their workflows to guide physician behavior and ensure that patients are receiving the most valuable imaging to guide their care.
1. Lee, DW, Rawson JV, and Wade, SW. Radiology benefit managers: cost saving or cost shifting? J Am Coll Radiol. 2011;8(6):393-401. Available at bit.ly/Radiology_BenefitManager.
By Kevin Wilcox, freelance writer, ACR Press