Experts see big implications for radiology in federal clinical decision support efforts

Most of the talk about changes in healthcare as it relates to radiology center on Medicare reimbursement levels. However, one piece that is yet to be discussed extensively but that has huge implications for radiology is clinical decision support.

As Diagnostic Imaging previously reported, computer physician order entry/clinical decision support (CPOE DS) is a tool that helps primary care physicians ascertain what test to order for their patients and circumvent the need for radiology benefit managers. Prior authorization for an exam is given in real-time with CPOE DS because the tool is based on appropriateness criteria, through an electronic rating instrument. Primary care physicians are not allowed to order tests helter-skelter; they are guided to order the proper test through a series of questions they answer electronically.

The healthcare bill now being discussed by Congress doesn’t mention radiology benefit managers (RBMs), despite their inclusion in the president’s budget recommendations. Credit for this goes to the Imaging e-Ordering Coalition, a group of healthcare providers, technology companies, and diagnostic imaging organizations that has been meeting with members of Congress regularly since June.

CPOE DS matches the Obama administration’s health information technology goals, promotes safety, quality, and documents appropriateness of care, said Liz Quam, executive director of the Quality Institute at the Center for Diagnostic Imaging, based in Minneapolis, and a member of the coalition.

“The coalition got involved because CPOE DS is so absolutely, fundamentally important to meaningful use, but it’s also fundamentally important to those of us who have to go to public policy types and say, ‘Don’t cut our reimbursement again. Instead, let’s make sure we can electronically document for you that the care that’s been given, the imaging scan that’s been provided, is clinically appropriate,’” she said. “And that’s what CPOE DS offers, that electronic documentation.”

The Senate healthcare reform bill says the act will vary “payment to physicians who order advanced diagnostic imaging services (as defined in section 13 1834(e)(1)(B)) according to the physician’s adherence to appropriateness criteria for the ordering of such services, as determined in consultation with physician specialty groups and other relevant stakeholders.”

The language is vague but it’s enough to send a message to all of the healthcare industry, whether RBM vendors or software developers: the federal government is serious about moving ahead with its health information technology goals, and that includes CPOE DS tools, Quam said.

“If it was a different kind of bill, and not this humongous 2000 page moving-mountains kind of bill, we would want it to be much more specific on what it says in there and how it’s done. But it’s fine. We’ll work with what we’ve got,” she said.

Even without the Congressional language, federal agencies will continue to push forward with clinical decision support. The two primary agencies to watch are the Office of the National Coordinator of Health Information Technology, which is working on electronic health record future criteria, often referred to as “meaningful use,” and the Centers for Medicare and Medicaid Services (CMS) , Quam said.

Indeed, another major piece of the CPOE DS puzzle is CMS’s previously announced demonstration project.

The demonstration project will likely have six sites and seeks to learn how good a job CPOE DS does in improving the quality of imaging referrals. By the time CMS is finished, there should be enough data for the federal government to determine how to use CPOE DS nationwide, if at all. The demonstrations are supposed to look at claims data as well as cost.

The demonstration project has serious ramifications for the nation because private health plans typically fall in line with whatever Medicare is doing. If the federal government mandates something for Medicare, the states use it for Medicaid. Medicare plus Medicaid makes up a sizable part of the market, and so instead of creating separate rules for the rest of the patient population, commercial health plans tell all the providers in their networks to comply with Medicare requirements.

“The federal government is big enough that when they set a rule, it’s really hard for providers to try and have dual standards, to comply with rules set up by someone like UnitedHealthcare if they conflict or aren’t consistent with what the feds have already told us to do,” Quam said. “It’s a bigger influence than sometimes Congress realizes.”

Because of the reach and repercussions of the CMS demonstration project, it’s important the projects are as robust as possible, she said.

“If it’s not robust, then it won’t show anything, it won’t show any value,” Quam said.

One concern is that CMS asked the coalition to boil down 15,000 clinical guidelines already in use to 2000, said Scott Cowsill, coalition chair and senior product manager for the healthcare diagnostics division at Nuance Communications.

“My concern is we boil it down to this very watery, vanilla-type flavor and at the end of the day the output or the data we’re going to get isn’t going to be as effective as if we used the robust CPOE DS we already have,” he said. “It would be nothing less than absolutely disastrous for me to hear them say, ‘Oh look CPOE DS doesn’t work. Thanks, though.’”

The Imaging e-Ordering Coalition wants the clinical guidelines to be specific, which means keeping the 15,000, and not generalizing. If they’re too general, they won’t apply to a lot of patient situations, Quam said.

“The products in the private sector have become more and more robust as they’ve been used, so this is like stepping back two or three years,” she said.

However, the Imaging e-Ordering Coalition continues to meet with CMS and Congressional members and staff to ensure the test is robust and that CPOE DS continues to be a part of the healthcare conversation. (See Nancy Koenig’s Jan. 19 DI blogpost. Koenig is president of Merge Healthcare Fusion.)