Clinical Decision Support for Radiology (CDS-R) - Proposal

1. Proposed Workitem: Clinical Decision Support for Radiology (CDS-R)

• Proposal Editor: Mike Bohl and Alicia Vasquez
• Editor: not known
• Date: N/A (Wiki keeps history)
• Version: N/A (Wiki keeps history)
• Domain: Radiology

2. The Problem

The current Scheduled Workflow Profile needs to be updated to reflect the new legislation mandating the use of clinical decision support (CDS) in imaging. As of January 1, 2017, all referring providers will need to use clinical decision support when ordering imaging exams. This use must be documented to CMS with the claim for the exam, so the information must flow through the imaging workflow. If this is not done correctly, CMS will withhold payment to the imaging provider. The establishment of an improved profile will help all stakeholders, from referring and imaging providers to EMR vendors and Clinical Decision Support vendors, to build a common framework that accommodates the new mandate. Use of this standard profile will improve the ability for all to implement the mandate efficiently, with higher usability at the outset. The cost associated with a poor implementation is large. Today there are over 370 million ambulatory imaging studies ordered annually, plus another share of the over 400 million hospital imaging studies that are considered outpatient.

An ordering process that changes to include CDS without proper standards and usability will incur extra time expense to the providers on both sides of the order, as well as additional integration expense. If these expenses, real or perceived, exceed the penalty set, the mandate will simply not be followed, and both the valuable clinical information stemming from the use of CDS, as well as the savings associated with more appropriate imaging, will be lost.

3. Key Use Case

Consider the following image order under the new mandate but without any standards: Dr. Mary Smith, an internist, is reviewing a Patient Joe Jones, who is complaining of back pain. She opts to send Joe for an MR of the Lumbar Spine with contrast. She knows that she is supposed to use CDS for this imaging exam. Dr. Smith enters the order in her EMR. Then she opens up a different application and re-enters the order information to get a CDS score. The score comes back low/inappropriate. Dr. Smith goes back into the EMR to look at the Joe’s chart to see if there is more information on his condition, and she looks at the CDS application to see if there is documentation of a more appropriate exam. She opts to stay with the current exam, but note that it is with or without contrast. She gets a CDS score or number, then she has to go back into the order in the EMR to revise it, and then manually add the number. She then faxes the order over to an imaging provider. The imaging provider, after receiving the faxed order and CDS verification code, manually inputs all of the order and CDS data and schedules the exam. Dr. Ann Andrews, a radiologist, protocols the exam and has concerns about aspects of it. She calls Dr. Smith to discuss. This information becomes a part of the radiology EMR, but does not populate back to the CDS system. The exam is performed, and the report created. At each step (Radiology EMR to transcription application to report), the CDS number has to be manually repeated. The report gets to the billing step, where the claim is halted because the CDS application used was not included. The biller has to call the office of Dr. Smith to get more information to properly file the claim. This use case is compounded if the exam must be revised, rescheduled, or if multiple exams are ordered for the same visit. In addition, this use case is specific to each referring physician office and each imaging provider, unless there is a standard.

4. Standards and Systems

The current Scheduled Workflow Standard includes many elements of an imaging order. It needs to be expanded to include the new CDS data specific to the mandate. There are additional elements that would be helpful to add as well, such as receiving facility. Other data included in standards could be improved, such as exam priority. The Profiles on PIX and PDQ are very helpful in this as well.

5. Discussion

IHE is the right approach to solving this issue, because it allows all stakeholders in the process to rely on a standard set of interactions, which improves the reliability of the process to the point where it can be used for the mandate. Risks in this include the current lack of common dictionaries for condition and procedure, as well as the high cost of utilizing HL7 for point-to-point interfaces.