Time to Get Ahead of the Curve: Clinical Decision Support Mandate Delayed, Not Dead

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Clinical decision support (CDS) tools have the potential to curb inappropriate imaging, reduce healthcare costs and improve the quality of care, according to data from the small number of early adopters in the United States. These clinicians are a step or two ahead of the Centers for Medicare & Medicaid Services (CMS), which last fall delayed implementation of the provision in the Protecting Access to Medicare Act (PAMA) that requires physicians to use CDS tools, and document their use, whenever they order advanced imaging tests. Cardiovascular Business spoke with physicians who are ahead of the CDS curve and others who are getting ready for its arrival.

The goal of the legislation requiring CDS was to help clinicians who order CT, MR, SPECT and PET imaging—often primary care providers and general cardiologists—to select the best test for each patient, depending on his or her clinical history, symptoms and demographics. According to the law, the CDS mandate was to take effect Jan. 1, 2017. Responding to a request from a coalition of 17 associations, CMS acknowledged that more time is needed to work out what will be required of practices and allow time to plan for implementation. At press time, CMS hadn’t set a new deadline for CDS use; however, a handful of hospitals have moved forward.

Why clinical decision support & why now?

“Studies show when clinicians don’t have [guidelines] information in front of them they don’t follow radiology guidelines about half of the time,” says Keith Dreyer, DO, PhD, vice chairman of radiology computing and information sciences at Massachusetts General Hospital (MGH) in Boston. That can increase costs, translate into poorer quality patient care and decrease patient safety by exposing patients to unnecessary radiation. In contrast, when guidelines are integrated into workflow at the point of care, physician adherence to guideline standards increases to 90 percent—“without the use of carrots or sticks,” Dreyer says. 

MGH started using decision support in 2004, initially for CT, MRI, nuclear medicine and PET. Computerized order entry systems and CDS tools weren’t yet available off-the-shelf, so MGH built its own.

CDS should be tied to electronic order entry and the electronic health record (EHR) to maximize efficiency and minimize workflow disruption. It’s also one of the reasons CMS had not pushed CDS until now: because workflow integration requires EHR integration and EHRs hadn’t reached the critical level of penetration. Now, EHR adoption has passed the 90 percent mark, spurring policymakers to push CDS.

Like EHRs, decision support requires well-devised operational and workflow planning. “The most arduous part of using clinical decision support is entering the reason for the exam,” Dreyer says. It has to be a structured reason. Every CDS system, whether from a vendor or homegrown, ties to structured content or guidelines, which are mapped to the reason for the exam and the exam itself. If the reason for the exam is entered as free text, then the CDS tool will show the physician all of the possible guidelines that relate to that reason—a figure that could stretch into the hundreds.

“If you give me the [structured] reason for the exam, I’ll show you the one targeted guideline that is appropriate for you to reference,” Dreyer says. Using a structured reason enables a straightforward connection between the indication and the guideline.

Another essential prerequisite for effective CDS implementation, according to Dreyer, is to integrate decision support into the workflow, providing ordering physicians with the information they need at the point of care without slowing them down. When a physician orders an imaging exam at MGH, he or she enters an exam and the reason for the exam. The system responds similar to a traffic light with green, yellow or red, indicating whether the exam is indicated, marginal or of low utility, respectively.

After the hospital implemented a hard-stop-on-red policy—it stopped performing exams likely to be negative unless authorized by a radiologist—low-yield CT, MRI and nuclear imaging exams dropped from 5.43 percent to 1.92 percent, and the probability of canceling those exams increased by 3.5-fold (Radiology 2010;255[3]:842-9). MGH also saw its per member/per month high-cost imaging exam volume drop 12 percent with CDS. 

Clinical decision support also has led to better collaboration between radiologists and ordering physicians at MGH, says Dreyer. When clinicians