Coalition Forms to Promote Clinical Decision-support Tools

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In June, an alliance of health care providers, technology vendors, and imaging organizations announced the formation of the Imaging e-Ordering Coalition, an initiative aimed at promoting health-IT–enabled clinical decision support as a means of determining the appropriateness of diagnostic imaging services. Members of the coalition include the ACR; the Center for Diagnostic Imaging (CDI), Minneapolis, Minnesota; and vendors that include Medicalis Corp (Kitchener, Ontario, Canada) and Nuance Communications Inc (Burlington, Massachusetts).
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Scott Coswill
“The goal of the initiative is to preserve the opportunity to use electronic decision support as an alternative to radiology benefit management (RBM) companies,” Scott Cowsill, cochair of the coalition and senior product manager of diagnostic imaging at Nuance Healthcare, explains. “Until recently, I think a lot of lawmakers thought RBMs were the only option they had, but the CMS demonstration project is coming up, and we don’t want anyone to jump the gun prior to seeing the project’s outcome.” The CMS demonstration project to test the effectiveness of prior-authorization programs is the result of a 2008 Government Accountability Office (GAO) study indicating that overutilization is occurring and, more controversially, all but endorsing outright the use of RBMs to reduce costs. “Several plans attributed substantial drops in annual spending increases on imaging services to the use of prior authorization,” the report states. “In contrast, CMS employs an array of retrospective payment safeguard activities that occur in the post-delivery phase of monitoring services and are focused on identifying medical claims that do not meet certain billing criteria. The private plans’ experience suggests that front-end management of these services could add to CMS’s prudent purchaser efforts.” The Minnesota Example The e-Ordering Coalition believes, however, that there is a more cost effective and accurate way to reduce costs while ensuring that patients get the imaging exams that they need. Founding member and cochair Liz Quam, director of CDI, has experienced it firsthand in Minnesota, where a group of insurers agreed to allow diagnostic imaging facilities to use electronic decision-support tools to curb overutilization. The homegrown program has resulted in both reduced costs and more efficient processes for referring physicians, who can check the appropriateness of a test while ordering it online, as opposed to spending time on the phone awaiting RBM approval. One participating health plan reported a 7,000-scan reduction among its membership in 2007, resulting in savings of around $6.6 million.² Patients also stand to benefit from e-ordering, Cowsill notes. “In my mind, this is a solution to benefit the entire enterprise triangle—the patient, the payor, and the provider,” he says. “When we talk about these things, no one really discusses return on investment on the patient side. People think utilization management is saying no to patients on certain tests, when in reality it’s saying yes to the right study for the right patient. If you’ve rearranged your day to get a CT, and you’re paying for it and taking time off work for it, you don’t want the test to be inconclusive.” When the GAO report was published last summer, Quam and Cowsill first began to discuss forming a coalition to promote the use of electronic decision support to lawmakers. “The GAO was recommending the use of some sort of RBM, and we knew that wasn’t going to be a good thing,” Cowsill recalls. “We began to gather support for the coalition and hired a firm in Washington, DC, to help us educate people on Capitol Hill. What we heard from people is that this is the option they’d been looking for, but they never knew it existed.” Cowsill points out that substantial efforts have been made, in Minnesota and elsewhere, to prove the effectiveness of RBM alternatives like clinical decision support. His worry is that federal entities could, with the stroke of a pen, make years of hard work worth nothing. He notes, “We don’t want to take three steps forward only to go 10 steps back because people don’t have the information they need to make an informed decision.” Opportunity Knocking Cowsill sees the recent passage of the American Recovery and Reinvestment Act as an opportunity. The legislation’s emphasis on the importance of interoperability, as well as its stipulation that meaningful use be established before an initiative for electronic medical records (EMRs) can receive federal stimulus money, may help prime lawmakers to be more accepting of integrated decision support. “Electronic decision support is far superior to trying to incorporate a phone call into the computerized physician order entry process,” Cowsill says. “Though the rule sets are proprietary at this point—we have our set, Medicalis has its set, and so on—they’re all based on ACR criteria, and at the end of the day they’re not that different. The objective is to plug them into the EMR in such a way that the system’s user sees the process as seamless.” Because many payors already use RBMs, with Cowsill estimating that 100 million patients’ imaging services are currently managed by them, it’s clear that insurers are willing to invest in some method of decision support. “We know the RBMs work because people continue to pay for them,” he says. “We also know that this method would be a fifth of the cost, and would be more efficient and patient centered. We want to show people that the rewards of this model far outweigh the costs.” The coalition is working to promote existing health IT legislation in the hope of informing lawmakers on the benefits of e-ordering. The group is also aiming to have its proposal scored by the Congressional Budget Office to validate its potential value to the health care industry. “The depth of the work our members have been able to do on such short notice is amazing,” Cowsill says. “We’ve submitted information to both the Senate Finance Committee and CMS. We hope to position the coalition as the go-to resource when it comes to these kinds of questions. Who knows the most about high-tech diagnostic imaging utilization management? We do. This is the most efficient, cost-effective, patient-centered way to make it palatable and appropriate for all parties. So far, there’s been no pushback. For once, we have consensus.” Cowsill invites those interested in joining the coalition to call its lobbying company, Holland & Knight (Washington, DC), at (202) 457-7004.