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Imaging Appropriateness: One Tool For All

Improving quality in radiology starts by ordering the right test at the time. But should one tool rule?


The use of evidence-based guidelines to help referring physicians and other providers make appropriate imaging and/or treatment decisions for specific clinical conditions goes back quite a few years.

The American College of Radiology (ACR) started developing guidelines—known as the ACR Appropriateness Criteria—for the correct use of imaging technologies back in 1993. The guidelines are developed by panels in diagnostic imaging, interventional radiology, and radiation oncology; and as of November 2013, they included 197 topics with over 900 variants.

According to Michael Bettmann, MD, professor of radiology at Wake Forest University Medical School and, until recently, the chairman of the ACR Appropriateness Criteria Oversight Committee, over those 20 years—and particularly over the last decade—there has been significant progress in the use of appropriateness criteria for imaging. “But the problem is that they aren’t necessarily being used in the right way, and they haven’t been incorporated properly into the way in which patient care is administered,” Bettmann said.

With this in mind, several years ago the leadership of ACR began considering the question of how it could distribute its appropriateness criteria “in a practical way as part of a physician’s normal workflow,” Bettmann said.

A decision was made to partner with a company called the National Decision Support Company (NDSC) of Andover, Mass, to commercialize the appropriateness criteria under the brand name ACR Select, which in a digital format provides EHR vendors like Epic with a direct method for healthcare organizations to integrate the ACR appropriateness criteria into their computerized ordering and electronic health record systems.

According to NDSC, more than 30 healthcare providers and radiology practices have now implemented ACR Select.

Why Clinical Decision Support?

The rapid increase in the utilization of advanced imaging in the decade leading up to the implementation of the Deficit Reduction Act in 2007—and the costs associated with all of those tests—led to concerns about whether imaging was being overused and questions about what could be done to ensure that it was being done appropriately.

Several clinical decision support (CDS) initiatives demonstrated the efficacy of CDS in increasing the rate of imaging that met appropriateness criteria, yet reduced overall imaging utilization. For example, in Minnesota, in the 3 years prior to 2006, high-tech diagnostic imaging utilization increased by 8% annually. But the introduction of a clinical decision support initiative in 2006 resulted in just a 1% growth in these exams in the 5 years between 2007 and 2012.

“The evidence is good that when you institute clinical decision support for radiology, you bend the growth curve of utilization of these expensive diagnostic imaging modalities,” said James McDonald, MD, vice chair of the department of radiology at the University of Arkansas for Medical Sciences. “Physicians are highly motivated to do the right thing—but even in specialty areas, physicians many times don’t know what the right test is to order, so that means there are a number of tests that shouldn’t have been done or should have been done in another way.”

As an example, McDonald pointed to a past experience he had with emergency room physicians concerning pulmonary embolism (PE) protocol CT scans. “In ER practice, they basically supplanted ventilated perfusion lung scans a long time ago,” he said, but the problem is that they come with substantial radiation dose.


What he advocated to his ER physicians was that in certain cases—such as a woman of child bearing age who complains of chest pains—a lung scan was in order if the patient had a clear chest x-ray and wasn’t wheezing, since “if the test is negative, it’s the best test in medicine for ruling out PE.”

“I had one informal discussion with them and their behavior changed overnight,” McDonald said. “Doctors just want to do the right thing—you just have to help them understand what the right thing is.” And that’s what CDS is designed to do, he added.

Other than the simple fact that it’s the “right thing to do,” McDonald said, there are substantive reasons for implementing clinical decision support.

For example, one of the first rules of patient care is “to do no harm,” pointed out McDonald, particularly when it comes to exams that involve exposure to radiation. If physicians can eliminate or reduce patient exposure to medical radiation through decision support, so much the better, said McDonald.

There are financial implications, as well, said Bettmann.  If imaging is being overused, that means the healthcare system is being overburdened financially, he said, “so if you follow the criteria, that should decrease costs.”

There is also the argument that by using clinical decision support and following appropriateness guidelines, physicians can protect themselves from litigation, Bettmann said.

With all of this in mind, McDonald began thinking about the need to implement clinical decision support at the University of Arkansas, particularly with the decision by the state to implement a new payment initiative—the Health Care Payment Improvement Initiative—which is an attempt to improve the quality of care by providing risk-based incentives to providers to deliver efficient, high-quality care.

It was also about this time that the university made the decision to invest in an installation of an EPIC electronic health system, through which it would be possible to implement ACR Select.

McDonald pushed for ACR Select adoption and got support from his chancellor, even when he explained that clinical decision support could negatively effect reimbursement by reducing imaging utilization.

“But he said, ‘It’s the right thing to do,’” McDonald recalled. “And, in reality, if [a test] won’t pass ACR Select muster, then the likelihood we get paid for it is small. So utilization will go down, we hope, and we believe that the tests that are going to get eliminated will predominately be tests we weren’t going to get paid for anyway. It’s kind of a leap of faith.”

The other factor to keep in mind, said McDonald, is that the Arkansas payment improvement initiative incentivizes providers who can lower costs while providing quality care, as compared to their peers. “If you’re one of the better performers, then you get incentivized with better payments the next year,” he pointed out. “It’s a brilliant system because it gives doctors an incentive to make good choices and gives radiologists an opportunity to distinguish themselves as real consultants. And I think tools like ACR Select will be a good way to help them.”

A National Standard?

The move toward clinical decision support could get a boost if the SGR (Sustainable Growth Rate) Repeal and Medicare Provider Payment Modernization Act of 2014 is eventually signed into law.

The bill, which has the support of the ACR, would require ordering physicians to use evidence-based decision support tools—such as ACR Select—to ensure advanced medical imaging tests or procedures are appropriate.

According to Bob Cooke, vice president of Marketing and Strategy for NDSC, one of the goals behind the decision to commercialize ACR Select is to establish “a national set of criteria for educating users on how to utilize imaging services—and to establish ACR and their appropriateness criteria as their standard.”

To be a standard, Cooke said, ACR Select needs to be accessible, consumable in “a meaningful, clinically relevant way,” there’s no vendor bias, and it has to be inexpensive enough “so that people aren’t thinking about the cost when it comes to implementing it.”

Right now, ACR Select customers are “a mix of enlightened people, with a focus on certain geographic areas where there is this focus on these kinds of quality utilization management initiatives,” said Cooke. “There’s a lot of activity in the Midwest.”

With its ongoing clinical decision support strategy, Minnesota is a particularly hot market for ACR Select. By the end of February of this year, more than 10 organizations across the state had adopted the tool.

As for the potential of CDS tools like ACR Select to replace other utilization management tools like radiology benefits management (RBM) companies, McDonald pointed out that if there is one thing that all doctors can agree on—radiologists and referring physicians alike—it’s that RBMs “are a pain in the butt.”

“The analogy I use is that radiology benefits managers are exactly like travel agents,” he said. “Thirty years ago, if you wanted to buy a plane ticket, you had to go through a travel agent, and this was just someone who sat at a computer looking at someone’s proprietary software and buying you a ticket. Now you just go online and do it yourself.”

RBMs are just a “1970s solution to a payment problem,” he said, and the solution seems to be this computerized evidence-based support—like ACR Select—that physicians can access in just a few clicks.

Cooke also said that considering there are direct costs associated with the use of

RBMs, ACR Select is something that payors should be particularly interested in. But they’ve been slow to adopt it.

“It’s a shift for them,” he said. “Yes, RBMs cost them money, but there are perceived savings there and they are comfortable [with using RBMs]. But we are starting to get them on board.”

An Alternative Model

One benefits management company with a model that’s different from the typical RBM is HealthHelp. HealthHelp is a specialty benefits management company that uses a “non-denial” model, said Anthony DeFrance, MD, chief medical officer of HealthHelp. “We don’t hard-deny care, so what we are counting on is that we can educate physicians so they can make more appropriate choices.”

Last year HealthHelp launched its own clinical decision support system called MedTree QDS, which has been integrated with its Consult program for radiology, cardiology, oncology, spinal surgery, and pain benefits management.

According to DeFrance, the appropriateness criteria used with HealthHelp’s CDS are “in alignment” with the criteria available from the ACR and other organizations like the American College of Cardiology. “The ACR’s rules are great, but there are gaps there and we have to fill them in,” said DeFrance. “I always emphasize that our rules are in alignment with theirs, but that our rules should be more extensive in terms of covering all of the possible things clinicians will call in for.”

The HealthHelp CDS tool is being rolled out piece by piece, and is currently being tested in some pilot markets. And while the response from users has been good, there are challenges, said DeFrance. For example, physicians typically have had to rely on office staff to get preauthorization for imaging exams, which means it wasn’t part of their workflow.

“That’s one of the biggest challenges we face in having a good CDS,” said DeFrance. “Making it so physicians can easily integrate it into their workflow, because if you can’t do that—and it’s not easy to use—then you’re going to get low adoption.”

This means that education plays a critical role in getting physicians to use the CDS, and to make it pay off. First, said DeFrance, physicians need to be educated as to why using clinical decision support makes sense, which means demonstrating to them that the CDS interface is easy to use, won’t interfere with their workflow, and will even help them reduce the number of full-time employees needed in their practice by eliminating the time spent by staff getting preauthorization.

Second, physician education comes in the form of showing them how to get the right test, at the right time, for the right indication. “One of the big advantages of clinical decision support,” DeFrance said, “is that it gives us the opportunity to educate clinicians as they are ordering tests, which will help them change their behavior over the long term so they start ordering more appropriate tests.”

Clearly, the push for the use of clinical decision support tools to help solve the problem of unnecessary imaging is here to stay. Only time will tell if ACR Select becomes the tool of choice.


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