ACR Select could lead to national guidelines for ordering exams
Article Thumbnail ImageJuly 18, 2012 -- The American College of Radiology (ACR) began publishing evidence-based guidelines relating to the appropriateness of ordering imaging exams almost 20 years ago. This year, its goal is to make the ACR Appropriateness Criteria the de facto national standard by commercializing them as a clinical decision-support system.
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Specifically, the ACR has entered into an exclusive agency agreement with the National Decision Support Company (NDSC) in Andover, MA, to commercialize its Appropriateness Criteria under the brand name ACR Select. NDSC is providing electronic health record (EHR) vendors with the technical platform, support, and licensing of ACR Select to be directly integrated into their computerized physician order-entry (CPOE) systems.

The ACR Appropriateness Criteria currently cover more than 1,380 topics and 614 variant conditions, and provide data-driven, evidence-based guidance for what types of imaging studies should be ordered and when. The database is continuously updated by more than 300 volunteer physicians serving on 20 specialty panels, representing more than 20 radiology and nonradiology organizations. Nine of the panels develop guidelines for radiotherapy treatment; these will not be included in the commercial clinical decision-support system.

Dr. Michael Bettmann, a professor of radiology at Wake Forest Baptist Health, chairs the ACR Appropriateness Criteria Oversight Committee, while Michael Mardini is NDSC's founder and CEO. AuntMinnie.com talked with them to learn more about the new project.

"The basic idea behind this initiative is that the ACR has an opportunity to make a huge, positive change relating to imaging exams that are ordered in the United States," Bettman said. "Approximately 20% to 30% of all imaging exams performed in the United States each year shouldn't have been ordered. We believe if our guidelines are adopted, they will make an impact in reducing the number of inappropriate imaging exams."

ACR believes that the initiative is a smart way to improve utilization, which is the goal of both Medicare and private payors trying to rein in rising healthcare costs.

"Times are changing," Bettman said. "The ACR and its members want imaging to be utilized correctly because that will benefit everybody: the patient, the provider, the payor, and our national economy," he stressed.

Bettmann pointed out that the timing of the project couldn't be better. The U.S. Office of the National Coordinator for Health Information Technology has incorporated the use of clinical decision support systems into meaningful use requirements. The Centers for Medicare and Medicaid Services has funded a multiyear $10 million Medicare Imaging Demonstration project to evaluate the efficacy of using clinical decision-support software, scheduled to be completed in April 2014. And Bettmann's committee members believe that the ACR has a robust database of guidelines that covers most applications.

The ACR believes the initiative will make the Appropriateness Criteria easier to use, which has been an issue with the guidelines in the past. Once they are integrated into a CPOE system, there won't be workflow interruptions. Physicians will be educated to make clinically appropriate decisions in real-time, supported by evidence, which also should have a positive impact if they share this information with patients, Bettman noted.

Mardini is equally enthusiastic. He is no stranger to commercializing clinical decision-support technology or, for that matter, heading innovative healthcare informatics companies. Mardini founded Talk Technology, one of the first companies to design and sell radiology and pathology speech recognition dictation systems.

After Talk Technology was purchased by Agfa HealthCare in 2001, he founded Commissure. Commissure, in addition to introducing a reporting system driven by multisite workflow and intelligent speech reporting, debuted RadPort, one of the first available commercial clinical decision-support software systems for medical imaging. After speech recognition and software developer Nuance Communications purchased Commissure in October 2007, the product continued to be sold until it was retired in June 2012.

NDSC has specifically positioned itself not to compete with CPOE vendors, Mardini said.

"The objective of the ACR is to have its evidence-based guidelines become the national standard for ordering diagnostic imaging exams," he said. "We want everyone to adopt this to make ACR Select a de facto standard. It will provide physicians with the most current medical imaging guidelines when they are ordering an exam in a workflow-efficient and transparent way."

ACR Select is based on an open standards platform that can be easily integrated with computerized ordering and EHR systems so healthcare organizations can effortlessly get access to ACR Appropriateness Criteria and ensure that the right patient gets the right scan for the right indication. A number of early-adopter EHR vendors have already integrated ACR Select, and NDSC is in the process of implementing agreements or in discussion with virtually all EHR vendors, Mardini said.

The product is being sold on either a site-specific or fee-per-use license. Hospitals that intend to use the guidelines for inpatient examinations and that know their exam volumes may opt for a site-specific license. Orders for outpatient imaging originating from numerous sources are better-suited for the usage-specific license.

"What's important is that the software is inexpensive. With the goal of establishing a standard, we understand that the guidelines need to be technically consumable, with no vendor bias, and pricing set so there is no financial hurdle that could deter its adoption and use," Mardini explained.

ACR Select was designed such that integration with EHR/CPOE systems will be as seamless and nondisruptive to ordering physicians as possible. In a properly integrated system, the ordering process should be identical to the current ordering process, unless the order is being placed for reasons deemed inappropriate by the guidelines.

What happens after that is determined by the customer. The healthcare provider has the option to intervene or not intervene into the exam ordering process. Or, users could add a layer of appropriateness analysis determined by local business rules.

ACR Select will also automatically provide recommendations for alternative exams, as well as educational material. NDSC will be evaluating data to identify specific exam usage patterns, levels of outliers, and where guidelines may need expansion and updates.

"We will be building feedback mechanisms. ACR Select contains sets of rules and criteria that encompass thousands of clinical scenarios and exam combinations, but vetting and additional evidence are an ongoing process," Mardini said.

NDSC will also be able to provide information to the ACR Appropriateness Criteria committee so that the guidelines can be continuously updated, Mardini said.

"We're looking forward to learning where referring clinicians believe there are gaps in guideline coverage, or what topics need expansion, clarification, or improvements," Bettmann concluded.