Why health systems must embrace the forthcoming CDS mandate

Upcoming legislation mandating the use of a clinical decision support (CDS) system when ordering advanced imaging tests could affect up to six million emergency department visits annually, according to estimates published in a Jan. 29 Radiology study. The law is set to go into effect in January 2020.

Congress passed The Protecting Access to Medicare Act (PAMA) in 2014, which put forth rules for CMS to establish the Appropriate Use Program for CDS systems that will be implemented in U.S. health systems serving Medicare beneficiaries. Providers who do not consult with a compliant CDS system will not be reimbursed for advanced imaging studies, according to the legislation.

A team led by Jahan Fahimi, MD, PhD, and Hemal K. Kanzaria, MD, each with the University of California, San Francisco, used data from the 2012-2015 National Hospital Ambulatory Care Survey to perform a cross-sectional analysis of ED visits. PAMA-related visits were chosen based on patient reasons for visit (RFV) in relation to the eight priority clinical areas (PCAs) outlined in the legislation. The group found more than 26 percent of patients (28,000,000 annual visits) visited with a reason consistent with one of the eight PCAs.

Additionally, among those PAMA PCA-compliant visits, up to 23 percent of patients underwent advanced imaging, adding up to nearly 6,000,000 million visits annually.

“These estimates are reasonable approximations of current ED ordering patterns of overall advanced imaging and PAMA-related advanced imaging,” the authors wrote. “However, the actual number of patient visits will depend on the choices health care systems make, further rule making by CMS, and other trends in advanced imaging.”

Over the first year implementing PAMA (2020-2021), CMS will not enforce a financial penalty, but will encourage health systems to comply by identifying ordering professionals who do not consult a CDS as often as others and requiring those outliers to obtain authorization for advanced imaging, according to the authors.

The idea is to reduce unnecessary imaging by addressing the eight clinical conditions due to their high frequency of associated imaging procedures. They are: coronary artery disease (suspected or diagnosed), suggestive pulmonary embolism, headache (traumatic and nontraumatic), hip pain, low back pain, shoulder pain (to include suspected rotator cuff injury), cancer of the lung (primary or metastatic, suggestive or diagnosed), and cervical or neck pain. These PCAs are found in one in four ED visits, according to the study.

“Whereas the actual effect of CDS on use and appropriateness from PAMA implementation is not yet known, this analysis highlights that a large number of patients in the ED, providers, and workflow pathways may be affected,” Fahimi, Kanzaria, and colleagues wrote.

In a related editorial, Howard P. Forman, MD, with Yale School of Medicine in New Haven, Connecticut, argued the implementation of PAMA largely depends on if ordering physicians, radiologists and health systems work together to comply with and even expand guidelines or choose to circumvent them.

“I would like to assure the reader that all of this will certainly have a measurable, positive impact on patient care,” Forman wrote. “But I cannot, as the evidence thus far is murky.”

In an ideal situation, Forman argued, the legislation could force ordering physicians to optimize their ordering of CT, MRI and PET/CT, which could produce better outcomes and lower healthcare costs.

However, will providers default responsibility and decision making to “an imperfect algorithm?” Can such legislation actually increase burnout? Nobody, including Forman, has that answer. But he suggested health systems invest heavily in the program and recognize initial growing pains can ultimately lead to better inpatient care.

“The opportunity to improve care delivery through evidence-based algorithms and guidelines is well documented but certainly not easy,” he concluded. “Therefore it is beholden to us, as professionals, to harness this opportunity for the good of patient care, help make it work, make midcourse corrections as needed, and advocate for changes, if necessary; our patients depend on it.”