RSNA13: Decision Support Indecision

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Should we or shouldn’t we? Despite the fact that legislators have signaled their willingness to make clinical decision support (CDS) for high-tech imaging part of legislation to permanently fix the SGR, this continues to be the question for a great number of radiologists.

After more than a dozen years in development, radiology decision support has reached a certain juncture. Bob Cooke, National Decision Support Company, which licenses the ACR appropriateness criteria as ACR Select, cites three milestones: The ICSI experience in Minnesota in which outpatient imaging utilization was flattened through the use of CDS; the Wisconsin legislation that allows the consultation of decision support in place of pre-authorization for high-tech imaging for Medicaid patients; and the aforementioned language in the SGR fix draft legislation.

Cooke points to a large number of radiologists who understand that assisting in the management of imaging utilization can enhance the radiologist’s value proposition. There apparently are, however, just as many who are on teh fence about adopting the role, most particularly in the academic setting. “This year at RSNA, we are announcing that people can sign up for trial access to our portal,” he invites.

Medicalis president and CEO, Oran Muduroglu, had no comment on the prospect of the draft legislation now in committee. “It’s such a political topic, we are trying to stay out,” he says. The company has incorporated the ACR Select catalog of content into what it calls a longitudinal platform in three dimensions for the management of productivity, quality, and utilization management. In the latter dimension, Muduroglu emphasizes the need to accommodate the local standard of care as well as the individual specialty of ordering physicians.

“We have this tool, then we say, when do you want to turn it on and when do you want to turn it off?” he says. For instance, a site may not have PET/CT, or it may not have someone to read MR at night, both of which impact the standard of care. And don’t, he says, ask a neurologist if a patient has a headache when he wants to order a head CT.

Health systems are not waiting for radiologists to answer the decision-support question. MedCurrent, a radiology decision-support company also exhibiting at the RSNA, recently announced a deal with AtlantiCare, a two hospital-system with a huge outpatient presence in New Jersey, and will begin a 90-day inpatient implementation in Q1, says CEO Jim Knickle. MedCurrent also has licensed the ACR Select appropriateness criteria, but maintains its own proprietary rule set as well, including a Rules Authority Studio that enables individual sites to tweak the rules.

“The RBMs do believe that they are providing good service, but we and many others believe that decision support is a much better way of providing the same service," says Steve Hermann, MD, MedCurrent CMO, citing lower cost and the educational value of the software. “Physicians prefer it, too.”

Meanwhile, as radiologists grapple with the whether or not to “own” decision support, RBMs are moving into the space. National Imaging Associates, owned by Magellan, recently announced that it has developed an advanced imaging decision support tool for the ED, an area of concern for many hospitals.

Liz Quam, longtime CDS champion in the outpatient world, member of the e-Orderlng Coalition, and executive director of CDI’s Quality Institute, is not surprised by the NIA move. “RBMs will just morph into something else,” she says. “They are like zombies: They never go away.”