How to implement clinical decision support: Part 1

By Erik L. Ridley, AuntMinnie staff writer

November 26, 2019 -- After years of delays, the era of mandated clinical decision support (CDS) for ordering advanced imaging studies for Medicare patients is finally at hand. It's time to get ready, according to presentations during a webinar hosted November 21 by the Society for Imaging Informatics in Medicine (SIIM).

"It's pretty clear now after the final rulemaking this year that CDS looks like it's coming," said Dr. Adam Flanders of Thomas Jefferson University Hospital in Philadelphia. "And we better be ready for it."

In talks during the SIIM webinar, Flanders, Dr. Richard Bruce of the University of Wisconsin, and Dr. Keith Hentel of Weill Cornell Medicine shared their experiences with adopting CDS.

Established via the Protecting Access to Medicare Act of 2014, the appropriate use criteria (AUC)/CDS program was initially pushed back several times by the U.S. Centers for Medicare and Medicaid Services (CMS) for a variety of reasons. However, as of January 1, 2020, ordering providers will need to consult AUC -- via a qualified clinical decision-support mechanism (CDSM) -- for ordering advanced diagnostic imaging studies (CT, MRI, PET/nuclear medicine) studies performed for Medicare Part B patients.

Either providers or the facility must append a new Healthcare Common Procedure Coding System (HCPCS) modifier to the Current Procedural Terminology (CPT) code as proof that the AUC consultation has occurred. A one-year educational and operations testing period will begin on January 1. Although AUC consultation information should be included with all CMS claims, no claims will be denied for the first year.

A serious financial impact

As of January 1, 2021, financial penalties will take effect and denials can be expected for claims that don't comply with the regulation, according to Flanders. Noncompliance will mean that no professional or technical fees will be paid by CMS for these imaging studies.

"So this could have a serious financial effect for radiology practices that have lots of [Medicare/Medicaid] patients," Flanders noted.

Beginning in approximately 2023, preauthorization may also be required for noncompliant providers that order imaging exams.

Flanders also pointed out that AUC consultation is required for advanced imaging services performed in physician offices, hospital outpatient departments, emergency departments, ambulatory surgical centers, independent diagnostic testing facilities, and any provider-led outpatient setting.

The definition of ordering professional is broad and would include resident physicians, physician assistants, nurse practitioners (or clinical nurse specialists), certified registered nurse anesthetists, certified nurse-midwives, clinical social workers, clinical psychologists, and registered dietitians or nutrition professionals, according to Flanders.

Appended claim information

The AUC consultation information must be appended on the professional and technical claims for the service. This appended information must include the ordering professional's National Provider Identifier (NPI) -- a unique code that indicates the CDSM that was used -- and a note that the service for the ordered indication did or did not meet criteria or is not applicable.

"The ordering professional does not have to interact with the decision-support mechanism," Flanders said. "Office staff under their direction can perform the consultation, but radiologists and staff cannot obtain the consultation. So it has to be done right by the ordering practices."

CMS has stated that it may make exceptions to AUC reporting requirements for emergency services when provided to patients with certain emergency medical conditions; inpatients and for which Medicare Part A payment is made; and ordering professionals experiencing a significant hardship, such as insufficient internet access and electronic health record or CDSM vendor issues; and extreme and uncontrollable circumstances, according to Flanders.

Based on their low adherence to AUC in priority areas, up to 5% of ordering professionals will be identified as outliers. This determination will be based on two years of data and may be based on comparison to other ordering professionals, he said.

"They may be forced to do a separate preauthorization process for any applicable imaging services," Flanders added.

Making CDS better

If your institution has already implemented a CDSM, is there a way to make it better? Flanders shared some tips from his three years of experience with CDS.

If you work in an all-inclusive, integrated environment where every ordering provider is in your electronic medical record (EMR) system, you've got nothing to worry about, he noted.

"Bills will be generated automatically; it's on the EMR company to do this," Flanders said. "All you have to do is purchase it and implement it and set it up with basic features."

Thomas Jefferson University Hospital, however, has a mixed environment; many of the ordering physicians are not part of the practice itself and still use paper scripts. Consequently, alternate preauthorization programs were needed, he said.

The institution utilizes a CDSM from National Decision Support Company that's integrated with its EMR software from Epic Systems. The CDSM software was also modified to only accept a structured indication for the reason for the exam; free-text input is only accepted if the ordering physician would like to add additional information or explain why they are choosing to continue with the order even if it's deemed to be inappropriate, according to Flanders.

"And that might be because the exam is not listed," he said. "It will give them the opportunity to enter the reason ... and we can modify our system to suit those physicians in the future."

The hospital also utilizes the Active Guidelines feature on the NSDC software, which begins the ordering process by starting with the actual clinical problem and then deciding on the most appropriate imaging test, he noted.

Structured indications

If you're interested in capturing the actual appropriateness scores from the CDSM for use in a quality assurance program, ordering providers need to be forced to use structured indications as the reason for the exam, according to Flanders. After switching to structured indications, 80% of orders have generated appropriateness scores, up from 20% of the exams with free-text indications.

But if you've allowed indications to be entered in free text before, the change to structured indications will require a strong, multipronged public relations program to all stakeholders, he said.

"If you're installing a new EMR with CDS, launch with structured indications right off the bat," Flanders said.

Gaming the system

Providers want to tell the truth, but given the option between telling the truth and saving time, they'll always pick saving time, Flanders noted.

"So you need to give people what they want," he added. "If there are any idiosyncratic indications at your institution like there are in ours, you gotta find ways to actually add them to the catalog to give your providers the opportunity to actually pick the structured indications that they would like to give you."

An independent portal can be an effective solution for dealing with paper scripts. Office staff can query the system and generate their own authorization number, which is then attached to the script and handed to the patient, Flanders said.

Part 2 of our coverage from SIIM's November 21 webinar on CDS will cover the experiences of and lessons learned by the Medical University of Wisconsin and Weill Cornell Medicine.


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