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

New U.S. legislation mandates the use of clinical decision support (CDS) when ordering imaging exams. As of January 1, 2017, CMS will withhold payment unless the referring provider documents use of CDS in the claim for the exam.

Today over 370 million ambulatory imaging studies are ordered annually in the U.S., plus another share of the over 400 million hospital imaging studies that are considered outpatient.

The data-flow and record-keeping necessary to comply would be difficult to do correctly and cost-effectively without automation and integration.

If the time, system and integration 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.

Need compliance data to be passed forward indicating the appropriateness of the order and the usage of compliant systems in the work chain.

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.
Dr. Smith knows that she is supposed to use CDS for this imaging exam. Dr. Smith enters the order in her EMR.
She then 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.
Dr. Smith opts to stay with the current exam, but notes 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 calls 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

Systems affected may include EMRs, CDS Systems, Ordering Placers, Order Fillers, Modalities, PACS, Billing.

IHE Scheduled Workflow already carries many elements of an imaging order through the radiology workflow. It could be expanded to include 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.

CDS is looking to industry for their suggestions on the content and format of the CDS number/dataset.

Most transactions already exist. Will need to add transactions to/from the CDS System to get the CDS Score based on the order details. (See IAC link below).

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.