Point-of-order clinical decision-support solutions assure that medically appropriate procedures are given the highest priority.
While research varies, studies report that up to 25 percent of imaging procedures are unnecessary, inappropriate or duplicative. Many health plans have instituted requirements for physicians to provide prior notification or to secure prior authorization. The process is telephone-based and, in many instances, administered by a third-party utilization-management company. In this model, a physician's office places a call to determine if an advanced study, such as an MRI, CT, PET or nuclear cardiology scan, will be covered for a patient's specific situation. Most require a preauthorization code in order to be reimbursed.
For both radiologists and their referring physicians, frustration can occur with these types of third-party pre-authorization processes. Doctors bear the financial overhead to acquire authorization for procedures, and must live with inefficiencies in the system. In many instances, physicians are given an inadequate explanation when approval is denied.
The Centers for Medicare and Medicaid Services is conducting a number of bundled payment pilots, and the ability to appropriately manage costs at the point of service could be required under future reimbursement systems. Pay-for-performance metrics are under consideration for increased Medicare reimbursement, with a requirement to utilize decision support in the patient's care. In some geographic areas, payers are incentivizing providers to use decision-support tools by waiving the preauthorization and paying claims for physicians whose orders fall within a specific range of compliance with the appropriateness criteria.
A clinical decision-support solution should ensure that the most medically appropriate procedures are given the highest priority and performed in the most-efficient way possible. Essentially, information technology helps each doctor order the right test, at the right time and for the right reason. The system should be available in the physician's office to provide support at the time care is being discussed with the patient and prior to ordering imaging procedures, especially advanced procedures.
The system should allow physicians to easily and logically enter patient history information and a chosen procedure and then immediately receive feedback about the appropriateness of the exam. The ordering physician should be able to secure an understanding of the clinical reasoning based on standards set by the American College of Radiology, and be able to understand the reasoning behind the feedback being offered.
The system should use technology to expedite and improve transmission of traditional paper- or telephone-based requests from physicians to specialists and specialized health facilities. Radiologists and imaging facilities should be notified when an order is placed, and when preauthorization is obtained.
These clinicians should have ready access to appropriate protocols for the specific patient's study. Imaging providers can eliminate the ordering and scheduling of inappropriate procedures before the patients are in the system and, subsequently, reduce claim denials and appeals. Patient care is improved because appropriate tests are ordered and administered.
A clinical decision-support system can automate the processes involved with securing pre-authorizations from insurers. For payers, this can help minimize the expense of establishing and maintaining a call center, and the work involved with telephone-based approval processes. Additionally, payers can overcome the perception that preauthorization decisions may be based on financial variables. A payer that uses a clinically based medical appropriateness decision-support system may be more readily perceived as a clinical partner in care decision making.
Models for deploying clinical decision-support systems are expanding, including recent availability of cloud-based software-as-a-service options and systems that readily embed into electronic medical records and portal environments. Yet, most current systems lack a fluid process for review, refinement and customization of rules that drive the system.
The system should utilize rule sets that are continually enriched and expanded for improved outcomes. Efficient updating should be possible based on ongoing procurement of new medical knowledge, including use of the system itself to gather and analyze the data it collects. Additionally, the system should allow individual users to create and submit rules that fit individual needs, and use them based on appropriate review and approval.
In a comprehensive project done in Minnesota in 2007, more than 2,300 of the state's providers participated in a pilot, using point-of-service decision-support criteria to order high-technology diagnostic imaging studies. Researchers saw claims for advanced imaging procedures among five health plans drop by 3 percent in 2007 versus 2006. Based on the previous four-year trend line, the reduction in claims was estimated at 9 percent.
A March 2010 study by researchers at the University of Washington's Harborview Medical Center in Seattle showed that more than 25 percent of outpatient CT and MR exams ordered by primary-care physicians at a hospital in Washington were inappropriate. The authors reviewed medical records from elective outpatient CT and MR examinations.
Of the 459 exams, 341 (74 percent) were considered appropriate, and 118 (26 percent) were not considered appropriate. Fifty-eight percent of the appropriate studies had positive results and affected subsequent management, whereas only 24 percent of inappropriate studies had positive results and affected management.
The researchers concluded that these results suggest a need for tools to help primary-care physicians improve the quality of imaging decision requests. “In the current environment, which stresses cost containment and comparative effectiveness,” they state, “traditional radiology benefit-management tools are being challenged by clinical decision support, with an emphasis on provider education coupled with electronic order-entry systems.”
Another study published in the February 2010 issue of The American Journal of Managed Care evaluated the effects of providing appropriateness criteria for advanced imaging procedures through guideline-based electronic health record decision support. Chart audits were performed on a random sample of adult primary care orders for CT, MRI of the head and MRI of the lumbar spine. Decision support was associated with a 20 percent to 36 percent drop in two of the three procedures. Results for the three procedures showed that a larger proportion of studies ordered after implementing decision support fit appropriateness criteria, and more post-implementation studies had the highest utility rating.
Systems designed to help clinicians identify and avoid unnecessary imaging procedures could bring annual savings of $35 billion to the nation's healthcare system. A clinical decision-support system designed with enough fluidity can be readily adapted for use beyond imaging, in specialities where established appropriateness criteria exist.
Stephen Herman, M.D., has served for more than 25 years as a radiologist at Toronto's University Health Network (UHN) and Mount Sinai Hospital. For more information on Medcurrent solutions: www.rsleads.com/005ht-206