Clinical Decision Support Order Appropriateness Tracking

Clinical Decision Support Order Appropriateness Tracking (CDS_OAT) captures and shares data elements produced by Clinical Decision Support systems.

Summary

CDS-OAT is a standard for the capturing and sharing of data elements related to the use of a clinical decision support system to evaluate the appropriateness of an exam. While it's development was prompted by the 2014 Protecting Access to Medicare Act in the United States, it was designed to be flexible and comprehensive enough to be used to report CDS results in health systems worldwide. Adherence to this profile will allow disparate systems to more easily accommodate the upstream or downstream data flows between the various systems involved in ordering, performing, reporting, and billing for imaging studies.

Benefits

CDS-OAT automates the capture, sharing, and reporting of CDS-related information required in the United States to receive payment, while allowing facilities and physicians to maintain a high degree of billing efficiency.

CDS-OAT also facilitates the review of ordering appropriateness patterns and use within their health system or physician group.

Failing to obtain and convey such CDS information will have significant financial implications in the U.S. (See Background below).

Details

The CDS-OAT information is carried in an OBX/NTE segment in a number of existing IHE Radiology Transactions based on HL7 2.5.1:

• RAD-2 Placer Order Management
• RAD-3 Filler Order Management
• RAD-4 Procedure Scheduled
• RAD-13 Procedure Update
• RAD-25 Charge Posted

NOTE: This profile conveys the CDS result. The actual interaction with the CDS system is defined elsewhere in the CDS-GAO Profile.

Background

In 2014, the US Congress passed the 2014 Protecting Access to Medicare Act (PAMA). This law mandated, among other things, that all physicians ordering “advanced imaging” (i.e., CT, MRI, Nuclear Medicine and PET studies) consult a Clinical Decision Support (CDS) tool when ordering advanced imaging exams (i.e., a CT, MRI, Nuclear Medicine, or PET study) on Medicare outpatients, and then provide the consultation result and other information to the facility performing, and the radiologist interpreting, the study. The law also required the performing ("furnishing") facility and radiologist to enter the consultation result on their claim form to receive payment for having provided the service.

While PAMA originally set a January 1, 2017 start date CMS delayed the start date to January 1, 2020. Further delay is not anticipated. This means that after January 1, 2020 payment for claim submitted by furnishing providers’ will be withheld if a) the CDS consult was not performed; or b) the furnishing provider’s claim does not have the required CDS results information on it.

Implications: The scale and scope of this mandate to US providers is staggering, and poses a significant threat to the financial health of the facilities and physicians providing advanced imaging services. The mandate requires CDS consultation information to be captured on every applicable Medicare study performed in the US, and then passed from the ordering provider to the facility for inclusion on the facility’s claims, while also being shared with the radiologist for inclusion on their claims. Failure to capture or to enter this information on the insurance claim will result in payment denial. Given the high level of automation in current radiology billing workflows, manual entry of this information would simply not a viable option: It would be cumbersome, time consuming and prone to error.

The challenge is that today’s systems are not designed to accommodate the mandate, and there was no standard for capturing and sharing the information between the various systems involved (e.g., EMR, HIS, RIS, Scheduling, Transcription, Billing system, etc.). This poses a real threat to imaging providers payments. Industry needed a solution for capturing and sharing the required information in a way that allowed the industry to maintain as much automation as possible, and it needed it quickly.

Recognizing this, representatives from several interested organizations proposed and supported the development in IHE Radiology 2014-15 cycle, of a framework for the capturing and sharing of CDS information. The result: Clinical Decision Support – Order Appropriateness (CDS-OAT) Tracking Profile.

Systems Affected

• hospital EMR
• hospital and office-based RIS systems
• medical billing systems

Beyond these primary systems, CDS information may be shared with the interpreting physicians via a data feed from the facility’s transcription system. Anyone responsible for radiologist billing may want to look at their facility’s transcription system as a potential source for obtaining the CDS result, and other required data elements.

Specification

Profile Status: Trial Implementation

CDS-OAT Supplement to the Technical Framework: [1]