Less Art, More Science

The image of the lone physician “listening for zebras” as he combs through a mental library of diagnoses is fast becoming a thing of the past. Some answers are objectively better than others, so the only real question is how to conveniently get those answers. In the radiology world, the “art of medicine” still applies to complex reads, but deciding which exams to order in the first place is decidedly more evidence-based. Fortunately, the American College of Radiology (ACR) has long cultivated national standards for imaging protocols. Until recently, this immense knowledge database, dubbed ACR Appropriateness Criteria® (AC), remained largely inconvenient to use due to their reliance on “paper.” In mid 2012, that all changed when the Massachusetts-based, National Decision Support Company (NDSC) engineered a digitally consumable format that could be readily incorporated into computerized ordering and electronic health record (EHR) systems. The ACR entered into an exclusive agency agreement with NDSC to provide the technical platform, support, and licensing of the AC under the trade name ACR Select™. The system improves crucial efficiency in an environment where radiology benefit manager (RBM) middlemen are watching every dime. “There is evidence and solid expert opinion as to which imaging exams to order under certain clinical conditions,” says Michael Mardini, CEO of NDSC. “The information is transparent and out there. The problem is that prior to ACR Select, the data was not organized algorithmically. It was essentially available in the form of white papers and PDFs..” According to Mardini, EHR vendors, referring physicians, and consulting radiologists now appreciate the ability to easily integrate and use AC guidelines in daily practice. “This is the electronic version of going to a library to find peer-reviewed data,” muses Mardini, a software veteran of more than two decades. Growing Acceptance of CDS Mardini contends that clinical decision support (CDS) is necessary in an era where referring physicians routinely see five patients per hour. “How do you take narrative text and make it meaningful and useful in a clinically relevant way?” he asks. “How do you do this in a manner that doesn’t disrupt the workflow of the ordering clinician? The ability to access evidence-based guidance from a credible source, at a clinically relevant time is crucial to improving clinical outcomes.” CDS for radiology ordering has been on the market for a number of years now. The prior challenges with acceptance have been two-fold. First, there has never been a clear set of guidelines produced and updated on a timely basis by a nationally recognized standards organization. Hence, gaining market-wide acceptance has been a challenge. Second, integration with the ordering process and related workflows has been difficult to accomplish. “With ACR Selct,” says Mardini, “both of these challenges are being successfully addressed.” Depending on the situation, it may be best to order MR, CT, or ultrasound. Factor in radiation exposure and cost, and suddenly the decision may not be so clear cut. Prior to CDS, there was no real-time guidance. And nowadays, the what, when, and how involves calling an insurance company for approval. The RBM company often sits between the payor and the ordering provider. The RBM’s job is to save the insurance company money. The good news is that the diligent physician who relies on CDS will likely get his exam done. Appropriateness scores of one through nine, a system started by the ACR, are still in effect with ACR Select. “It might be a nine for CT, a seven for MR, and a four for ultrasound,” explains Mardini. “The scores correspond to the likelihood that the exam you are ordering is going to give you the answers you are looking for. In instances where there is documented evidence, an additional link to a white paper tells referring docs why the MRI is better than the CT—and how the advice was derived. “The initial excitement of EMRs was converting from paper, but this is the promise of EMRs,” enthuses Mardini. “It is having real-time data, real-time feedback, and evidence. It is CDS that will improve clinical outcomes and improve efficiencies in health care.” A Matter of Philosophy Mardini acknowledges that not every situation has a white paper and a 2-year study, so the nature of decision-making is not always so clear-cut. “If you put 10 physicians in a room and ask a question, you could get 15 different opinions,” he says with a chuckle. “That said, we look forward to hearing from clinicians and getting their feedback. In fact, we are expecting these interactions to help the ACR update and improve the guidelines in a real-time, market-, and physician-centric manner. That interaction is a key component to the value of what we and the ACR are offering.” Ongoing additions to the knowledge database are meant to maintain the vibrancy of a CDS cache that already has more than 130 topics and 614 variant conditions that provide evidence-based guidance for appropriate utilization of medical-imaging procedures. More than 300 volunteer physicians, representing radiology and non-radiology specialty organizations, participate on the ACR-AC expert panels. These panels continually update the guidelines. CDS makes sense in virtually every health-care environment. With the emergence of accountable-care organizations (ACOs) and, generally, shared-risk programs, the motivation to keep costs down and reduce unnecessary procedures is shared by payors and providers. Why would radiologists care? Because, ultimately, in shared-risk programs (as opposed to fee-for-service models), clinician salaries and the procedures they perform are bottom-line costs. Providing standards and proper protocols for patient care is tantamount to running a successful health-care service. Like all clinicians, radiologists must prove their worth—and participating in programs that provide clinical value is important. “It’s that simple,” Mardini says. “CDS for appropriate ordering, as driven by ACR guidelines, is a key first step to maintaining the stellar standards of the radiology profession that we all rely on.” Greg Thompson is a contributing writer for imagingBiz, Tustin, California.