Appropriate Use Criteria: Health IT Creates Gateway for Gatekeepers

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The growth in imaging study volume has come under fire in recent years. The figures are staggering. Advanced imaging services spending by Medicare, including for CT, MRI and nuclear medicine, increased from $3.6 billion to $7.6 billion from 2000 through 2006, representing a 17 percent average increase annually. U.S. expenditures on medical imaging are approaching $100 billion.

The American College of Radiology (ACR) Appropriateness Use Criteria (AUC) provides a mechanism for curbing growth by seeking to determine if a particular imaging exam is appropriate for a specific patient condition. While clinical implementation of these protocols has been slow, the increased deployment of health IT may facilitate greater adoption of AUC. Early feedback from sites that have leveraged IT to support appropriate exam ordering is positive. However, widespread implementation hinges on education, sustained commitment from professional societies, incentives and perhaps, legislation.

Where are we now?

Begun in 1993, the ACR AUC covers 167 topics. The criteria have been developed by 10 diagnostic imaging expert panels and an interventional radiology panel, in conjunction with 20 medical specialty organizations. Since 2005, the ACR, along with the American College of Cardiology (ACC) and other societies, have developed several appropriate use protocols for each of the major cardiac imaging modalities, including SPECT myocardial perfusion imaging, cardiac CT, cardiac MR and stress echocardiography.

“In the last five years, the level of collaboration between the professional societies to develop superior AUC best practices has skyrocketed,” notes James H. Thrall, MD, ACR president and chief radiologist at Massachusetts General Hospital (MGH) in Boston.

Despite these efforts, widespread AUC adoption is still in its “very early stages,” says Todd D. Miller, MD, of the nuclear cardiology department at Mayo Clinic in Rochester, Minn. While clinical studies suggest the inappropriate use level of cardiac SPECT is 15 percent across the U.S., for example, Miller suspects that it must be closer to 50 percent in some practices because of the national rate of imaging growth. Similarly, a retrospective review of 459 CT and MRI studies to determine AUC usage pegged 74 percent as appropriate and 26 as not appropriate (J Am Coll Radiol 2010;7:192-197).     

To combat inappropriate use of imaging, professional societies are working for better dissemination and improved adoption of AUC. The ACR recently posted protocols online and made them available for handheld devices. The ACC launched the FOCUS initiative to help practices best use AUC at the point of care; the online community provides a forum for participants to share ways to maximize AUC use and includes educational resources.

The effort also extends to individual institutions. Hospitals such as MGH have built the ACR Appropriateness Criteria into computerized order entry (CPOE) systems.

However, the lack of mandate to implement AUC creates a conundrum. The burden lies on the individual radiologist, practice or department to adopt protocols, which may contradict the bottom line. “Traditionally, radiology practices and departments have been asked to open access as much as possible, encourage throughput as much as possible, generate as much revenue as possible—all while maintaining a high level of efficiency and maximizing the business,” explains Alexander M. Norbash, MD, chief of radiology at Boston University Medical Center. “This kind of a fee-for-service attitude runs counter to considering how equipment can be best utilized for each individual patient, and to only perform imaging tests when necessary.”

“Only recently have radiologists been in the position of rejecting inappropriate studies. For the radiologist to become a ‘gatekeeper,’ who oversees appropriateness and is empowered to divert or cancel a significant percentage of studies, it will require a dramatic change in the traditional role, especially when we contrast this new role with that of the radiologist as an imaging facilitator,” Norbash adds. For this transition to occur, he suggests that referring physicians will have to become equally educated about AUC protocols to “work as a unified team with the radiologist.”

The health IT foundation

To properly utilize AUC protocols at the point of care, most physicians concur that health IT is necessary.

Until EMRs and CPOEs become more widespread, the adoption of AUC at the point of test ordering is “unlikely to occur,” writes Ella A. Kazerooni, MD, director of cardiothoracic radiology at University of Michigan in Ann Arbor, who adds that even with “healthcare reform and financial inducements, the implementation of EMR systems will be slow,” (Am J Roentgenol 2010;195:968-973).

Thrall suggests that the recent HITECH Act, which earmarked $20 billion for health IT adoption, will help facilitate the AUC process. “Most contemporary EHR or EMR systems, hospital information systems, practice management systems can be adapted for CPOE or already have CPOE systems embedded within,” he says.

Early data suggest CDS can spur change. The CDS program that MGH tested in its CPOE, which provides recommendations to referring physicians when studies are requested, has resulted in an attenuation of the rate of imaging utilization increase, despite the ability of ordering physicians to override program recommendations.

Thrall points out that CDS systems can be customized with AUC, providing the appropriate information at the point of care. “In our own system, we built a duplicate exam alert. If a physician doesn’t realize that a patient had the same or similar exam within the last two or three months, the CPOE system automatically cautions the physician that he may be ordering a duplicate exam,” he explains.

Norbash suggests that a lack of health IT tools shouldn’t be an excuse for a practice not to engage in the AUC process. “If a provider has very little in the way of resources, the physicians still want to be thoughtful in terms of how they use the imaging protocols; it might even be more important,” he says.

However, Thrall acknowledges it is “very cumbersome” to access AUC without a computer system, because the physician is forced to sift through a “protocol book with hundreds and hundreds of examples.” Yet, he also stresses that a physician champion could be a game changer for any practice, even those that do not have comprehensive health IT solutions.

Patient data: A missing link

In addition to the need for greater health IT adoption, the incomplete nature of patient records complicates the process. In one of the few prospective studies assessing AUC using a computer-based tool, Hendel et al found that coronary heart disease risk could not be calculated in 17 percent of patients, and some dates for revascularization procedures were not available (J Am Coll Cardiol 2010;55:156-162). “The inability to collect complete data for common clinical variables at the point of ordering highlights that application of AUC is not necessarily simple,” says Miller.

“Hendel et al’s study was unique because the researchers collected data at the point of ordering,” says Miller. “Therefore, the ability to collect all data should have been 100 percent, but instead, 6.7 percent of the study population could not be assigned an appropriateness indication. And of that 6.7 percent, the reason was incomplete data in 75.6 percent.”

As a result, IT adoption alone cannot solve the conundrum of how to properly adopt and utilize AUC protocols. “Common clinical characteristics, such as cholesterol or the date of a previous revascularization, are often missing from medical records,” adds Miller, who notes this may improve with the HITECH Act pushing EMR adoption and standardization.  

Alternative to RBMs

Third-party payors more frequently require preauthorization by radiology benefit management companies (RBM), a process that Miller characterizes as “time consuming and frustrating for caregivers.”

If a practice or department determines a study is necessary, a nurse needs to call the RBM telephone number for approval, which can take anywhere from two minutes to longer than a half-hour, Miller explains. “When a caregiver is tied up with a process that equates to 100 percent of downtime, it is highly inefficient.” Also, the healthcare professionals often have “no idea on what basis the RBM bases its decision,” he adds.

Alternatively, if AUC is incorporated into CPOE systems, it “fits into the work process of the referring physician, who can enter the exam and patient selection into the computer, and the answer is returned very quickly,” Thrall says. “Physicians far prefer CPOE with CDS for appropriateness of use, compared with having to leave the patient, make a phone call, wait on hold or speak with up to three different people and in the end, not understand the answer they receive. As more electronic information systems become available, a computer-based approach with AUC will gain more widespread acceptance, and have a greater utility than the RBM approach.”

This alternative approach could cause payors to re-examine the process of imaging reimbursement. “Importantly, this type of software could bring about automatic billing from third-party payors, rather than going on the billing circuit where the payors try to resist all exams that we attempt to bill for because a significant percentage is redundant imaging, in their attempt to figure out what tests are irrelevant to the patient’s care,” Norbash says. “In addition to facilitating improved patient care, it also guarantees payment because the third-party payors have also agreed on the sensibility of those particular entry criteria for imaging.”

Also, Norbash adds that radiology departments and practices need to maximize revenues they recoup, so “we push the correct buttons where signs and symptoms are concerned and third-party payors will reimburse us … whether the payor is government or insurance.” He says the process ultimately needs “buy-in from RBMs and payors.”

Next step: Engaging the payors

Professional organizations are attempting to work with payors to bring about change and collaboratively develop systems of care.

Discussions are underway with several health plans about adoption of alternatives to RBMs, based on the AUC and tied to quality improvement and education tools. For instance, the ACC Medical Director’s Institute is working with payors, like UnitedHealthcare, to pilot AUC as a CDS tool.  

“It’s inevitable that practices will be incentivized for adopting AUC because imaging is a significant driver of healthcare costs—particularly redundant imaging—and financial incentives will mobilize universal acceptance,” Norbash says. “Or, third-party payors could mandate this to decrease total payouts, creating a process that would be a little more confrontational. Clearly, if there is an added benefit, a certain percentile added for the practices that employ AUC, it’s more likely to be accepted earlier.”

Whether AUC is incentivized or not, it may soon be mandated, as federal and state governments look to curtail medical costs associated with imaging. “Unfortunately, it often takes legislation, like the recent California radiation dose tracking [law], to facilitate action for healthcare providers,” Thrall observes. That law is first across the country.

Government intervention doesn’t necessarily “put the proper tools in place for doctors to actually undertake what the legislation requires,” he adds. “Therefore, the professional societies will remain important for tools, such as the ACR registry system for radiation dose, for mammography callback rates and other markers of quality and safety. While it often takes legislation to capture people’s attention, it takes organizations that understand the domain to put the practical solutions in place.”

Due to pressure from a variety of sources, appropriate use criteria seem like they are here to stay, with health IT easing and facilitating adoption. In addition to curbing inappropriate use and its associated costs, AUC could potentially translate to increased practice revenue by improving communication and buy-in about quality markers with payors.