ACR Supports the Appropriate Decision

"The limitation of the ethical phenomenon to its place and time does not imply its rejection by, on the contrary, its validation. One does not use cannons to shoot sparrows." — Dietrich Bonhoeffer, Ethics1ACR supports decision

The ACR Appropriateness Criteria® are evidence-based guidelines intended to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for specific clinical circumstances. These criteria now cover over 180 topics and 900 variants.

Expert panels in diagnostic imaging and radiation oncology develop these guidelines. The panels include not only radiologists but also representatives from other specialties.

It was in the 1990s that ACR recognized the need for what was to become known as the Appropriateness Criteria. In 1993, Karl K. Wallace, MD, FACR, former chair of the BOC, testified before Congress that ACR was ready to create guidelines for radiology in hopes of eliminating inappropriate imaging services. A task force was set up and, in 1994, deliberations began. The task force incorporated guidance from the Agency for Healthcare Research and Quality and from the Institute of Medicine. The methodology relied primarily on peer-reviewed evidence from publications, where available, and used the Delphi methodology to achieve expert consensus. Physicians from medical specialties other than radiology were included and provided important clinical perspectives.

The ACR Appropriateness Criteria were distributed to members in booklets and on CD-ROMs. Frankly, they did not receive much attention and were not widely used.

But times have changed, and now the Appropriateness Criteria are about to take off. Decision support is the next big thing. ACR has partnered with the National Decision Support Company (NDSC) to deliver the Appropriateness Criteria in a product called ACR Select™. The criteria are now organized in a manner such that the diagnostic radiology guidelines can be integrated in the electronic medical record (EMR) order-entry process. This provides a user-friendly, seamless method of access and education for ordering providers. ACR Select guidelines will be continuously updated and supported by ACR's Appropriateness Panels.

So how does this work? Vendors, such as Epic and Cerner, can purchase and integrate ACR Select into their products. ACR Select can also be retrofitted into an existing EMR or embedded in a newly deployed package in a hospital or other facility that performs imaging studies. When a health-care provider enters an order for imaging into the EMR, a screen pops up on the workstation, with the relevant Appropriateness Criteria for that specific clinical circumstance. Various studies and procedures are ranked in terms of appropriateness and level of radiation. The ordering physician can then click on references that substantiate the recommendations. The ordering provider can then choose to follow the recommendation or not. Clinical information, captured by ACR Select and provided to ACR, will provide a continuous and secure flow of information among health-care organizations, NDCS, and the ACR. It is expected that this will identify areas for improvement to better meet actual clinical needs.

What does this mean for hospitals and accountable care organizations? ACR Select can help health-care providers manage expenses by providing clinical decision support for both inpatient and emergency care. It can also aid in reducing radiation exposure as well as patient length of stay.

How will this impact the payer and ordering clinician? ACR Select will replace the traditional pre-authorization programs in outpatient settings. This can eliminate the costly and inefficient radiology benefits management programs by replacing pre-authorization and the associated phone calls. The College hopes this will foster positive behavior modification based on education at the point of order, without being a gatekeeper process.

What about the radiologist? ACR Select re-establishes radiology and the radiologist as the preeminent managers and experts on diagnostic imaging and therapy. This is a first step toward reengaging an important and valuable resource in the clinical care continuum: the radiologist.

By taking a greater role in the care of their patients, radiologists can act in a consultative capacity when the guidelines are not completely conclusive or when the clinician has additional questions. Proper implementation can facilitate easy communication between the ordering physician or other provider and the radiologist at the point of order.

Payment methods are changing, and unit pricing is being reduced. Risk is being passed to the provider. ACR Select has the potential to place radiologists back into a cognitive, consultative role in patient care and bring them to the table in discussions on cost savings and care efficiency. The partnership between the College and NDSC delivers on the promise of appropriate medical imaging and therapy, which has the potential to reduce the number of invasive surgeries, cut back on unnecessary hospital admissions, shorten length of stay, and greatly improve patient care.

"My number one thing is to work on is not being reactive - but appropriateness doesn't come easily to me sometimes." — Courtney Love

ellenbogenBy Paul H. Ellenbogen, MD, FACR, Chair



1. Bonhoeffer, Dietrich and Green, Clifford J. Ethics, third edition. Augsburg Fortress Publishing, 2005.

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