Daily Bulletin 2015

CMS Mandate Delayed, But Implementation Should Move Forward

Wednesday, Dec. 02, 2015

From left: Jeffrey B. Weilburg, M.D., Jennifer K. Coleman, Mark D. Hiatt, M.D., Joseph Hutter, M.D.

From left: Jeffrey B. Weilburg, M.D., Jennifer K. Coleman, Mark D. Hiatt, M.D., Joseph Hutter, M.D.

Despite the postponement of a key mandate in the Protecting Access to Medicare Act (PAMA) of 2014, stakeholders should not delay in their preparation, according to a panel of experts speaking Tuesday.

The Centers for Medicare & Medicaid Services (CMS) announced in October that approved mechanisms for the implementation of clinical decision support (CDS) software would not be in place by the Jan. 1, 2017, deadline. The provision was included in PAMA to mandate that ordering providers consult appropriate use criteria (AUC) via electronic CDS for outpatient advanced imaging exams for Medicare patients.

"We're not even sure when the new mandate deadline will come to pass, but now is the time to prepare," said panelist Mark D. Hiatt, M.D., executive medical director of Regence BlueCross BlueShield of Utah.

Creating and implementing AUC is a complicated and time-consuming process. Panelist Joseph Hutter, M.D., lieutenant commander, U.S. Public Health Service, said it can take 12 to 18 months just to upload AUC into the CDS tools that will be used at a particular institution.

Dr. Hiatt said for a CDS to be successful, the user interface must be efficient, intuitive and accurate. The platform must be fast and efficient in mining content. Clinical content must be comprehensive and editable. And it must be able to analyze and act on data.

Although the mandate is government-generated, Dr. Hutter said he sees it as a partnership between public and private entities rather than a government program.

"This program will fail if it becomes just another government compliance checklist," he said.

Despite the difficulty in establishing CDS, it is a positive improvement over the pre-authorization process, which can be fraught with complications and unintended consequences. Jennifer K. Coleman experienced that in Michigan when a regional health plan implemented the process in the early 2000s.

She found the process negatively impacted the workflow and encouraged "work-arounds" such as not ordering appropriate imaging only to avoid the hassle. To Coleman, the process also puts the emphasis on the cost of utilization rather than quality.

"How wonderful would it be to say, 'Regardless of the cost, we're going to do what's right for the patient,'" said Coleman, executive director of Grand Traverse Radiologists, PC, and president of the Radiology Business Managers of Michigan. "That's a great measure to go after."

According to Coleman, CMS addresses that shortcoming.

"At the end of the day, CDS provides appropriate imaging that is patient specific, provider endorsed and results in appropriate costs," Coleman said.

Staff at Massachusetts General Hospital (MGH) report a similar experience. MGH implemented its own CDS within its radiology order entry (ROE) prior to the mandate.

The MGH system created suite reports that generated appropriateness scores for each physician. The reports were shared among the physicians so they could learn if they were requesting too many imaging tests compared to their colleagues.

MGH is currently working on adding total cost and clinical outcomes to the suites report to help further explain why one physician may have a high user rate than another.

"The goal of this was not simply to reduce utilization," said Jeffrey B. Weilburg, M.D., associate medical director, Massachusetts General Physicians Organization. "The goal was to implement optimal utilization."

Question of the Day:

I am treating a patient for thyroid cancer with Iodine 131. He makes pasta for a living and wants to know when he can go back to work.

Tip of the day:

Tendons and ligaments may experience "magic angle artifacts" caused by very short T2 times when the tightly bound collagen is at ~55 degrees from the main magnetic field.

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