Radiologists: Time to Aggressively Adopt ACR Select

January 14, 2014

Imaging is over utilized, and utilization will be managed. Clinical decision support is the best compromise, and ACR Select is the answer. Here’s why.

We should, more often, declare our ideological conflict of interest. This can be more revealing than a CT vendor paying for your Hershey Bar.

Let me declare mine. I am an orthodox techno-neutral radiologist nostalgic of the good ol' days when interposed between the clinician's requests and imaging stood the implacable physiognomy of an unflappable radiologist.

There is ideology and there is reality.

Reality is that as inappropriately low the clinical threshold for ordering imaging often is, it is unlikely to re-ascend the heights of the yester years. This is true not just for the US but for the UK where diagnostic medicine is changing and thresholds for requesting CT are falling (UK is US minus ten years on many matters, other than gun ownership).

Reality is that radiologists do not wish to question the referring physician about the appropriateness of the study. Being a nice person is morally (and financially) rewarding, leads to job security and increases the bonuses. Obstructionist radiologists do not score very high on customer satisfaction surveys.

Reality is that payers will manage utilization. If they do not trust that radiologists are able and willing to take this role (they don't) they will hire third party agents: radiology business management associations (RBMAs). But before you draw the crosshairs realize that shooting RBMAs would be like shooting the messenger.

Reality is that radiologists will enhance their value by actively managing utilization of imaging.

Reality is that realities often conflict. I like beer. I do not like being endowed with a triple chin. Conflicting realities.

Let's summarize the realities: imaging is over utilized, it’s over utilized unevenly, it is logistically impossible to run all imaging requests past the radiologist for appropriateness and relevance, utilization will be managed, radiologists do not like confronting referring physicians, radiologists that manage utilization will be valuable.

This is tough. It's like trying to displease your mother, mother-in-law, wife and best friend simultaneously.

With these competing realities clinical decision support (CDS) offers an acceptable compromise. National Decision Support, under partnership and guidance of the American College of Radiology, has produced ACR Select.

The CDS interposes evidence-based appropriateness score between the clinical condition for which imaging is requested and the modality requested.

If the clinician requests MRI of the brain for focal neurological deficit this receives an appropriateness score of nine. This is feedback that the right study has been requested for the right indication.

If the clinician requests CT for suspected infection of the ankle in a diabetic ankle the appropriateness score flashes one. This is feedback that the wrong study is being considered. This is particularly important in the emergency department where a CT may be ordered not because it is helpful but because it is there.

Understand that presently no feedback is being offered to clinicians whatsoever. Note two things taking place with CDS. First, the feedback. Second, the documentation. Record is made of good ordering, bad ordering or, most pleasing of all, conversion of bad ordering to good ordering.

Or, evidence of the right test to order, evidence that right tests are ordered and evidence that wrong tests are ordered. Evidence, evidence, evidence.

Data are important. The radiologist can approach the boundlessly affable Dr. Hormesis, who has taken the "beneficial effects of low dose radiation" to heart and wishes to apply this paradigm to his patients, and say "positivity for CT angiograms that you order is 0.1 percent, the national mean is 20 times higher. What gives?"

In the old payment model Dr. Hormesis would be Chairman-preferred frequent flyer, on the golf course with the CEO of the radiology practice. In emerging capitated payment models, Dr. Hormesis's over utilization of imaging for Peter affects both Peter (less in the bundle for Peter) and Paul. He has support neither of Peter nor Paul.

Will feedback change the culture of ordering? May be. May be not. But gains will be realized at the margins. And progress must start at the margin and work centripetally.

ACR Select is an adjunct to utilization management. It is not intended to, indeed it cannot, replace a radiologist's conversation with the clinician. It is intended to generate those clinical scenarios that most merit discussion so that these discussions are appropriate, valuable and not intrusive.

The success of ACR Select depends on radiologists for many reasons. Their willingness to learn the system. Their willingness to teach clinicians about the system. Their willingness to collect and act on the data generated by the system.

The CDS will strengthen with iteration. Iteration needs adoption, unconditional widespread adoption. Healthcare domains vary. Healthcare practitioners vary. Any attempt to fit all with one size is bound to fail. However, if radiologists work with their local CMIO they can temper the nuances, so that the CDS is adjusted for the thrifty electrophysiologist differently from Dr. Hormesis.

This a two way street. Consider, for example, that several physicians are ordering a test for a certain diagnostic condition that consistently receives poor appropriateness score. There are several interpretations. First, that the clinicians need education. Second, the appropriateness for that indication needs to be revisited. Third, this represents an area of need where research dollars can be allocated to find better tests.

The gulf between radiologists and clinical context is large but not unbridgeable. In order to re-capture relevance radiologists must offer consultative services. We will find in ACR Select a useful tool. But it will only help us if we wish to be helped.