A number of different methods can be used to implement radiology clinical decision support (CDS), but whatever's chosen must be easy to use and integrated into the ordering physician's workflow, according to talks during a webinar hosted by the Society for Imaging Informatics in Medicine (SIIM) on November 21.
These issues are important and time-sensitive. As of January 1, 2020, ordering physicians will need to consult appropriate use criteria (AUC) via a qualified clinical decision-support mechanism (CDSM) prior to ordering advanced imaging studies. After a one-year grace period during which no financial penalties will be imposed, failure to comply with the AUC/CDS requirement of the Protecting Access to Medicare Act of 2014 (PAMA) may result in denial of claims as of January 1, 2021.
Following up on a presentation by Dr. Adam Flanders of Thomas Jefferson University Hospital in Philadelphia during the SIIM webinar, Dr. Keith Hentel of Weill Cornell Medicine in New York City and Dr. Richard Bruce of the University of Wisconsin shared their experience with CDS and suggestions on how to achieve a successful implementation. Part 1 of our two-part series on the SIIM webinar on CDS is available here.
A three-pronged approach
Weill Cornell Physicians Organization has 10 years of experience with CDS integrated with its enterprise electronic health record (EHR) software, Hentel said. The organization is also a qualified provider-led entity under the PAMA AUC/CDS program, allowing it to create its own appropriate use criteria or endorse other AUC.
Weill Cornell uses a three-pronged approach to CDS. The foundation is the integration with its EHR software (Epic Systems), Hentel said. CDS is applied to all patients across its enterprise, not just Medicare patients.
"What's good for one is good for all," he said.
The CDS is tailored based on provider type; a primary-care physician might not get the same number of alerts that a subspecialty neurologist or a neurosurgeon might receive, Hentel said.
Not every provider is within the institution's HER system, however, so not all orders are transmitted electronically, he said.
"We still deal with a lot of paper orders, a lot of fax orders, and a lot of patients and offices calling up to schedule by phone without even providing us a representative of a paper order at the time that they're scheduling," Hentel said.
Compliance with PAMA's AUC/CDS requirements for advanced imaging orders includes ensuring that the decision-support interaction has taken place and that the required G-code (an identifier of the specific clinical decision-support mechanism used for the consultation) and Healthcare Common Procedure Coding System (HCPCS) modifier are added to the Medicare claim, he said. A copy of the decision-support number should also be retained in the event of an audit.
Easy to use
Given the competitive environment that Weill Cornell exists in, it's critical that its CDS approach be easy to use for providers who send orders from outside of its HER system, according to Hentel.
"If I provide something that's complicated and cumbersome and somebody else can provide something that's easy to use, they're not going to use our system, and they're not going to send their patients to us," he said.
For those ordering providers who are not part of the Weill Cornell HER system, the organization provides CDS via an integrated portal. After a referring physician logs in, they can select an imaging exam to order. The decision-support software will then launch and appears the same as it does within the core EHR software, Hentel said.
Once the decision-support process has been completed, the ordering provider can then schedule the exam on behalf of the patient on the integrated portal, he noted. An EHR-integrated portal offers opportunities such as ease of use, reduced data entry, branding for practices, and feedback reporting to providers. In addition, the required information for billing is included in the order/metadata, according to Hentel.
Despite these advantages, there's been a lot of pushback from nonaffiliated providers, Hentel said. To address these adoption challenges, the group endeavored to make the CDS process as efficient as possible.
"We've added one-click orders and tried to decrease data entry whenever possible and added real-time scheduling," he said. "We've shown how it can significantly decrease the number of phone calls, which is something referring providers' offices generally are in favor of. And we can even provide access to reports and images through our standalone portal, making it a more valuable tool for our providers."
Hentel believes the PAMA requirement to use AUC/CDS will be the tipping point, however, to drive providers to use the integrated portal.
He noted that security is an important concern when deciding to implement an integrated portal. It's important to work with your IT and security departments, Hentel said.
Also, "you really need to start curating your provider database, because having a clean database and knowing who you have to reach out to [are] crucial," he added.
For those providers who did not wish to sign up to use the integrated portal, Weill Cornell will also offer a standalone portal that providers can use without entering any protected health information (PHI). The portal will generate a decision-support number and an outcome that can be printed and then sent or faxed over.
Standalone portals offer benefits such as ease of use, no or minimal credentialing, and avoiding the need to enter PHI. It also offers the opportunity for branding, Hentel said. On the downside, it requires a lot of duplicate data entry.
"It is preauthorization-type workflow," he said. "You're going to generate a number and then it's going to, at least at our practice, be up to our preauthorization staff to make sure that that appropriate information has been transmitted to us by the time the encounter happened."
The standalone portal also enables other types of professionals besides the ordering physician to interact with the CDS, Hentel noted.
No matter which of these CDS approaches your institution goes with -- and Hentel recommends choosing more than one -- now's the time to start putting together information and begin marketing to your referring providers so that they know what's going to happen next year. There are still a lot of providers out there who don't have access to an EHR system with a qualified decision-support mechanism, he said.
"Ordering providers and imaging practices need to have solutions by next year, " he noted.
Imaging practices should analyze their nonelectronic referrals, figure out how many they have, where they are coming from, and determine what their strategy is going to be, Hentel said.
For their part, ordering providers should work with their imaging practices they refer patients to in order to understand their options. They should also think about how they will use and integrate CDS into their workflow, he said.
"Also, train your preauthorization and office staff because they're going to be responsible for that as well," Hentel said.
University of Wisconsin experience
The University of Wisconsin was another early adopter of CDS, having fully integrated imaging CDS since 2011, according to Dr. Richard Bruce. The institution was also one of the participants in the Medicare Imaging Demonstration project.
The university utilizes CDS for all patients regardless of carrier and across the gamut of advanced medical imaging, Bruce said. The institution also uses an integrated provider portal with outside providers.
Workflow integration is crucial for radiology CDS, according to Bruce. CDS can be integrated with the Epic EHR software in two ways: Epic's Order Composer functionality or a separate ordering mechanism for imaging.
Utilizing Order Composer offers several advantages, including enabling a unified ordering workflow for all orders. The user interface is completely built into Epic's software, and users can leverage Epic order optimizations, such as preference lists and order sets. On the downside, the user interface is constrained by Epic, Bruce said.
"Regardless of what product you're integrating, when you're looking at what the provider experience is going to be, this is a really crucial decision," he said.
Approximately 20% of orders, however, are not placed through the integrated portal. Bruce noted, though, that a number of outside providers have been reaching out to the institution recently to ask how these orders are going to be handled now.
"So I'm actually very optimistic," Bruce said. "It's just great to see traction of outside physician practices be very interested in how to solve this."
The institution is heavily invested in looking how to change some of these outside practices from faxing orders to direct integration with Epic software, he said.
In addition to ensuring compliance with the law, CDS can enable radiology departments to better understand provider patterns and provide feedback, according to Bruce.
"We are now at the point where we can get very rich and useful data," he said. "And this could be the starting point of a quality conversation with a lot of these departments. ... We can look at a given department and practice patterns and say, 'Hey, there may be opportunities here for us to help you or to help your providers or to understand your providers better.' "
Compliance with PAMA is doable, Bruce noted.
"And I'm optimistic that [CDS] does serve as a catalyst to really help us provide better services in the end for all of our referring providers," he said.