Bill Pushes CDS Forward with Potentially Positive Impact on Radiology

April 10, 2014

Recently-passed legislation would make clinical decision support use mandatory and improve appropriateness guidelines for ordering diagnostic imaging.

Clinical decision support (CDS) tools are one step closer to being mandated under federal law. A new, recently-passed bill from the U.S. House of Representatives is the latest legislative effort aimed at making this technology part of standard best practices.

The bill, approved Monday, March 31, would require referring and ordering providers to consult with physician-developed appropriateness guidelines when deciding on an advanced diagnostic imaging study. The American College of Radiology (ACR) participated in crafting the legislation and has long advocated for the use of clinical decision support systems, such as its own ACR Select.

If the bill becomes law, it could have a significant, positive impact on how diagnostic imaging services are used in healthcare environments, Cindy Moran, ACR’s assistant executive director, told Diagnostic Imaging.

“Using CDS tools embedded with physician-developed appropriateness criteria will ultimately improve the accurate ordering of advanced diagnostic studies and ensure the appropriate studies are done for the right reason on the right patient,” she said. “We think this is absolutely the poster child of where policymakers want to go across the board for all issues of care.”

If signed into law, this legislation would go into effect in 2017 and would include benchmarks to ensure correct use.

Support on the Ground

Enthusiasm for legislation requiring the use of CDS tools goes beyond the ACR. There’s great support for it at the provider level, as well, said Safwan Halabi, MD, radiologist and director of imaging informatics at Henry Ford Health System.

“There’s more and more strength behind CDS. Not only with imaging, but also in general with the way medicine is being rolled out,” said Halabi, who also spoke about legislative efforts around CDS tools at the 2013 Radiological Society of North America annual meeting. “Especially since electronic medical records are push[[{"type":"media","view_mode":"media_crop","fid":"23888","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_2598742770128","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"1994","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 230px; width: 299px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":" ","typeof":"foaf:Image"}}]]ing decision support.”

Many providers, he said, would like to see the Centers for Medicare & Medicaid Services and other payers give preference or access to providers who use CDS instead of relying on radiology benefit management (RBM) companies or pre-authorization processes.

This desire, Moran said, extends to physician groups at the national level.

“The physician sitting there with the patient and trying to determine the appropriate imaging study for their diagnosis – they want these tools,” she said. “Everything we’ve heard from their associations, they don’t like the mandatory pre-authorization or RBMs. That’s a uniform consensus.”

It’s possible – and likely – she said that state governments will see this federal legislation as a roadmap for effectively using CDS tools. The ACR’s hope, she added, that they respond positively and embrace this trend.

However, there are barriers to widespread CDS acceptance and adoption, Halabi said. In the current fee-for-service environment, there is little incentive to implement a system that could curb imaging use in any way. But as more institutions move to accountable care organizations or some other type of shared-responsibility network, using CDS to help control unnecessary and inappropriate utilization will likely become more common, he said.

In fact, some states are already progressing in this direction. In 2010, Minnesota launched a statewide initiative for CDS adoption, and according to the 2013 Minnesota e-Health Initiative Report, up to 78 percent of referring physicians are using one or more CDS tool features. Wisconsin, North Carolina and Washington have also considered statewide moves in this direction, Halabi said.

Impact on Radiologists

While using CDS tools will be an adjustment for many referring and ordering physicians, radiologists will also need to alter the way they practiced, said Jonathan Breslau, MD, president and chair of the board of the Radiological Associates of Sacramento.

“Radiologists need to expect to be engaged more consistently with doctors at the point of care,” he said. “Whether it’s having a department ‘bat phone’ or something else that lives in the electronic medical record, radiologists should expect they’ll need to be more available to help guide and support imaging recommendations – especially when no imaging is appropriate.”

The optimal strategy, Breslau said, is for radiologists, referring clinicians, and administrators to discuss the best path for their institution together.

Overall, however, the specifics and strategies around implementing and enforcing nationwide CDS use are still fluid. But the push in this direction, Moran said, is strongly positive.

“I’m hopeful that this is going to be a first step in a more thoughtful approach by Congress,” she said. “We’re doing everything we can to ensure the appropriate utilization of diagnostic imaging.”