Owning Clinical Decision Support

Collaborating clinicians should champion CDS tools to ensure best imaging practices.

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As radiologists push forward in providing the high-value and appropriate imaging that best serves their patients, an opportunity for collaboration, cost-savings, and better patient outcomes is at hand. By working with referring physicians who are unsettled by CMS’ Appropriate Use Criteria (AUC) mandate under PAMA, radiologists can ease the adoption process and maximize the value CDS delivers.

It behooves radiologists to help referring clinicians understand the value that evidence-based CDS brings to the table. But that can be a hard sell, says Arun Krishnaraj, MD, MPH, vice chair for quality and safety at the University of Virginia Health System. “Some physicians mistakenly see CDS as a loss of control — as a system that’s being imposed on them,” he says. “Their frustration isn’t necessarily with following AUC, but with what they see as an obstacle to something that was previously easier to do. There is substantial literature that shows CDS works and is superior to the current system, and we need to raise the education level around that.”1,2

The ACR has heard concerns from some members about a lack of awareness by referring providers around using CDS before ordering advanced diagnostic imaging for Medicare patients. In response, the College provides an AUC toolkit that explains requirements under PAMA so that radiologists can better educate referrers on the process. The ACR, in collaboration with RBMA, has also created resources to prepare referring physicians for the CMS mandate and to keep them apprised on any changes to the AUC requirement.

Referring Support

There are many benefits of CDS, says Christopher M. Gaskin, MD, FACR, associate chief medical information officer at the University of Virginia Health System. Ordering imaging tests can be confusing for referring clinicians, Gaskin says, and CDS provides assistance at the point of order entry — when it is most appropriate and likely to save time on the back end.

“When considering the numerous advanced imaging tests — such as whether to use contrast or not — CDS offers standardized, expert assistance to order the best test the first time,” Gaskin says. “This potentially helps patients avoid unnecessary radiation exposure and the substantial costs associated with unnecessary or less beneficial tests.”

The feedback ordering physicians get when using CDS includes potential alternative tests in the context of their patient’s clinical scenario, Gaskin says. That feedback can be tailored by patient age, gender, clinical setting, the ordering provider’s specialty, and other factors. “This can help ensure the process is efficient, focused, relevant, and high-yield. Other information on costs, radiation dose, and any relevant literature can be offered for additional guidance,” he says.

Sometimes providers may feel pressured by patients or families to order low-value advanced imaging tests in an attempt to provide definitive answers, Gaskin says. In these cases, CDS can provide objective support for why a test isn’t being ordered, leading to an opportunity for shared decision-making and improved patient-centered care. “Essentially,” Gaskin says, “CDS adds to documentation justifying clinical decision-making.”

Collaborative Process

Putting CDS into full effect means respectfully engaging referrers to get them on board, says Sarah E. Reimer, MD, radiologist and researcher with Aurora Health Care in Milwaukee. “This needs to start in the early stages of CDS implementation. Referrers must have a say and a chance to raise concerns about gaps in content — and receive a response to their concerns.”

Time spent on implementation should be a consideration. For instance, vendors may not have the full picture of the installing organization and can be overly optimistic about the time and effort required to get a CDS system up and running at a particular site, Reimer says. “There needs to be substantial engagement and an investment of time by both radiologists and referring providers. Time spent on CDS education and change management is not billed, but it's definitely part of the overall cost of good implementation,” she notes.

Studies show that specific design features of CDS systems need to be thoroughly evaluated to determine how best to reduce inappropriate high-cost imaging at your institution or community.2 CDS developers need input from the people who will actually be using the system, Krishnaraj says. When there is apprehension, he says, “we need to say, ‘I understand this may be frustrating for you, but that’s exactly why I need your help.’” Referring providers should know that the front-end time they spend on CDS will be given back to them in abundance once the process is in place, he adds.

When encouraging ordering providers to participate, you can emphasize potential credit earned under the Merit-Based Incentive Payment System (MIPS). Referring
providers should also be aware that their clinical staff can use CDS and report back results — potentially freeing up time.3

Showing Value

Relatively minor implementation costs and time spent on education and training are well worth the effort, Krishnaraj says. The value of CDS is evident in its potential to bypass prior authorization, to bolster referrers’ knowledge of the types of exams available, and to ensure adherence to guidelines and standardization across the entire healthcare system, he says.

There is a growing evidence base showing that CDS can replace prior authorization — resulting in increased clinician autonomy, more patient-centered care, and more cost-effective outcomes. “When you can use CDS to bypass preauthorization or a radiology benefits management company from the intermediate step of
ordering, processing, and scheduling a study,” Krishnaraj says, “it obviously saves time.”

“Some payers are starting to consider using appropriate CDS scores to help expedite the preauthorization process,” Gaskin says. “There is potential to lessen the
preauthorization burden for all involved parties. If a substantial number of ordered tests can be deemed likely to be appropriate by an automated process, then it can
allow human resources to focus their prior authorization efforts on a smaller set of orders that are at higher risk of being inappropriate. This could be a big win.”

“If we can leverage CDS to get relief from prior authorization, we should,” Reimer points out. Her group is applying for a prior authorization waiver based on its use of CDS and a quality improvement plan. They hope to increase referrers’ scores with CDS by boosting their “green rate” — showing improved performance in the
eyes of CMS — for studies ordered.

The plan is to send “red rate” reports for individual providers to their respective service line leaders as part of the quality improvement plan. The reports would show
the likelihood of a provider ordering an inappropriate exam relative to their peers.

“We are trying to match providers with high red rates — those who CMS might identify in the future as outliers — with an appropriate radiologist who can go through their ordering patterns and identify what is driving up their red rate,” Reimer says.

Forward-thinking radiologists are prioritizing conversations with referring providers around the benefits of CDS. All radiologists should be talking to referring clinicians who need guidance — and taking advantage of free education and implementation resources (see sidebar on page 14). Explain what you hope to accomplish with CDS. Talk about the size and scope of the system, discuss the vendors you have in mind, and point referrers to all available resources on using AUC and implementing CDS.

Radiology needs a deeper integration of referring providers with radiologists in the implementation of CDS to make it as smooth and user-friendly as possible, says
Krishnaraj. “If they feel like something is being thrust upon them, it’s not going to work,” he says. To that end, try to get the referrers who are most resistant to CDS
involved with its development. “Find out what is concerning them and what would make ordering easier for them,” says Krishnaraj. “Then they become part of the

By Chad Hudnall, senior writer, ACR Press

1. Huber TC, Krishnaraj A, Patrie J, Gaskin CM. Impact
of a commercially available clinical decision support
program on provider ordering habits. J Am Coll Radiol.
2. Doyle J, Abraham S, Feeney L, Finkelstein A, et al.
Clinical decision support for high-cost imaging: a
randomized clinical trial. PLoS One. March 15, 2019.
3. Lane E, Kosse C. Imaging CDS begins in 2020: get the 6
latest updates. Advisory Board. Dec. 4, 2018. Available CDS_2020.

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