Clinical Decision Support for

Medical Imaging

Update on activities

July 23, 2015

12-1pm

Work Group on a Standard Imaging Order

Agenda

July 23, 2015Work Group on a Standard Imaging

Order

1. Welcome

2. A little background refresher

3. Current progress

4. Next Steps - how to stay engaged

2

A little background refresher…

3

Our Work Group

� The Work Group on a Standard Imaging Order was

formed at the request of the eOrdering Coalition

� The Work Group started when Clinical Decision

Support for the ordering of advanced imaging moved

from an option to a legislative reality

� The Work Group co-chairs were named by the

eOrdering Coalition

4

eOrdering efforts gained a legislative solution

in 2014

Protecting Access to Medicare Act of 2014 H.R.4302

� SGR patch

� Delayed ICD-10

� Section 218: Mandates the consult of appropriateness criteria in the ordering of any advanced imaging exam

-Referring clinicians are required to use CDS but only the provider who does the imaging study will be denied payment if there is not decision support verification.

-Leaves it up to the Medicare agency to set the rules for how the process for submitting claims with decision support verification is done and what guidelines content is acceptable.

5

PAMA Specifics on CDS

1. Mandates that physicians and other providers consult with

appropriate use criteria (AUC) when ordering advanced diagnostic

imaging (MRI, CT, NM, PET) for their Medicare patients

2. Rendering facilities and interpreting physicians must provide

documentation that AUC was consulted in order to be paid by

Medicare

3. The consultation requirement is effective on January 1, 2017

4. Ordering professionals identified as outliers versus their peers will

be subject to prior-authorization beginning on January 1, 2020

5. Claims affected: PC, TC, Global, and HOPPS

6. Exclusions: Emergency services, inpatient services (Part A) and

significant hardship (case-by-case; e.g., rural without sufficient

internet access)

6

More PAMA Specifics on CDS

� Appropriate Use Criteria: criteria to assist in decision making that are developed or endorsed by National Medical Specialty Societies or other Provider-Led entities that are, to the extent feasible, evidence based;

� No later than November 15, 2015, HHS shall via rulemaking specify AUCs only from those developed or endorsed by National Medical Specialty

Societies or other Provider-Led Entities.

� Not later than April 1, 2016 (and annually thereafter), HHS will identify an initial list of Qualified Clinical Decision Support Mechanisms

� HHS shall identify on an annual basis no more than 5% of Ordering Professionals who are Outlier Ordering Professionals with respect to Applicable Imaging Services. This determination is made using not less than two years of data, beginning with 2017 data

� Beginning January 1, 2020, HHS shall require prior authorization for the ordering of Applicable Imaging Services by an Outlier Ordering Professional

7

Why is this so hard? Components of an Order

� Order number (linked to accession number) – no common standard

� Patient demographics –matching criteria ( First, Las, DOB), including email

address, method of contact (phone, email, etc)

� Guarantor information -

� Payer information – no common standard

� CDS score – no common standard

� Exam to be performed – no common standard

� Clinical information, including reason for the exam – somewhat standardized

� Referring and CC physician information – NPI standard

� Valid physician electronic signature

� Exam priority – limited standard

� Order status (new, reschedule, etc) – limited standard

� Date - standard

8

The Life of an Order

9

• Physician/Staff

ENTER INFO

• Physician/Staff

SAVE

• Physician

SIGN

• Physician

SUBMIT

• Hospital or imaging ctr

SCHEDULE

• Radiologist

CLINIICAL REVIEW

• Imaging Center/ Third party

PRE-AUTHORIZE

• Radiologist

CREATE REPORT

• Fax, HL7

DELIVER REPORT

Order of steps can vary by provider, image center or hospital, and type of

order. Adding CDS data to this process today would be largely manual

and subject to error.

Evidence-Based Medicine Cycle

Patient-Specific Clinical Indicators Identified in EMR

or CPOE

Patient-Specific Appropriateness Scores Returned

AnalyticsReviewedClinical Outcomes

Analyzed

Request Procedur

e

Imaging Procedure

Requested by Physician

Procedure Conducted

IncrementalRule

Developed

If: then

Ordering Feedback

Received by Physician

Order Placed

Order

Improved Care, Lower Costs

10

Bottom Line for the Work Group

� Create an imaging electronic order standard that can be utilized consistently throughout the industry for the placement of imaging orders, both high tech (CDS required) and low tech orders.

� Job One – the ability to electronically move the CDS code or number from the ordering provider to the rendering

provider allowing capture for the inclusion on the claim.

� Ensure that the electronic order is:

� Accurate, transmittable, efficient and printable

11

Time Check

� CDS requirement goes into effect January 1,2017 for all advanced imaging

� Means technology should be tested and usable by October 1, 2016

� Means standard should get to all vendors by October 1, 2015

� Means standard is developed, understood and accepted by CMS by March, 2015

12

Current Progress

13

Areas of Effort

� Define the order and process: Work with IHE to modifying the current Radiology Scheduled Workflow Profile to include the required CDS data. Add support of CDS information as well as other improvements to standardize overall order content and format.

� Mechanisms and Standards for Data Exchange: Working to determine the most efficient and least costly way to send and receive order information and reports

� Dictionaries and Informatics: Work to establish standard dictionaries for key data elements wherever possible. Work with CDS vendors to provide this information in a consistent fashion via a query of the CDS number.

14

Standards-Based Solution

� The Integrated Health Enterprise (IHE) organization was

identified as the best alternative to define a standard

process for the interaction and delivery of Decision

Support.

� CDS and EMR vendors were solicited for involvement

with the IHE definition of the approach which recently

completed and released for public comment.

� Two different Profiles working in conjunction to

complete the entire workflow (PCC and Rad IT)

� Profiles entering public comment phase and will be

ready for testing / implementation in time for 01/2016

15

IHE: A Framework for Interoperability

• A common framework for harmonizing and implementing multiple standards

� Application-to-application

� System-to-system

� Setting-to-setting

� Enables seamless health information movement within and between enterprises, regions, nations

� Promotes unbiased selection and coordinated use of established healthcare and IT standards to address specific clinical needs

17

IHE Profile Cycle Stages

MembershipStatus

Open Date Close Date Learn More

Call for Proposal Open July, 2014 30 Aug 2014 http://wiki.ihe.net/index.php?title=Radiology_Proposals_2012-2013

Proposal Selection Closedn/a

25 Oct 2014 http://wiki.ihe.net/index.php?title=Radiology

IHE Profiles drafted in IHE Committees

Closed Nov 12, 2014 15 Feb 2015 < ditto >

Public Comment Open 27 Feb 2015 27 March2015

http://www.ihe.net/Technical_Framework/public_comment.cfm

Trial Implementation Published

Open n/a

May2015 http://www.ihe.net/Technical_Framework/index.cfm

IHE Connectathon Registration

Open Aug 2015 Oct 2015 http://www.ihe.net/Connectathon/index.cfm

IHE NA Connectathon Dates

Open Jan 2016 Feb 2016 < ditto >

Dates are subject to change Please check wiki.ihe.net and click on Radiology

Thank you to Chris Lindop for this content

Current IHE status

� Patient Care Coordination Proposal (PCC)

� Was submitted to and accepted by the IHE� http://wiki.ihe.net/index.php?title=PCC_PC_ProposalReview_20141017#Clinical_Decision_Su

pport_for_Radiology

� Author is Chris Lindop

� Public comment period completed, profile being finalized with anticipated release in August

� CDS Order Appropriateness Tracking (CDS-OAT)

� Was submitted to and accepted by IHE� http://wiki.ihe.net/index.php?title=Radiology_Proposals_2014-2015#Brief_Proposals

� Authors are John DeLong and Teri Sippel-Schmidt

� Public comment period completed

� Final profile published in June 2015

� Providers have joined IHE

� Guidance from IHE members has been strong

42

Standards-Based Solution

CPOE Decision Support MechanismDecision Support Mechanism

AU

C

#3

AU

C

#3

AU

C

#n

AU

C

#n

AU

C

#2

AU

C

#2

AU

C

#1

AU

C

#1

Radiology Information

System

Billing System

CMS

Patient Care Coordination IHE ProfileScope

Radiology IT IHE ProfileScope

� Interaction with Decision Support

� Communication of Decision Support

19

Fax

Basic CDS Radiology Profile

We now have

the pathway

defined.

We are still

missing the

data definition

from CMS

Some members of eOrdering signed on

to a CMS letter in December

21

The letter gained us a meeting in March

We want to work with CMS to help ensure the

successful implementation of section 218(b) of the

Protecting Access to Medicare Act (PAMA) of 2014:

� Efficient

� Useable

� Reliable

� Consistent

22

We are here, not to discuss the clinical aspects of CDS, but

rather the mechanics of its implementation.

Imaging Orders

23

Electronic Requisition

HL7

The Typical Imaging Order

24

Paper Requisition

The final step

25

CMS 1500

Our Request

�There needs to be a common way to communicate CDS information:

� For electronic orders:� Automate the transmit of CDS information from the ordering provider to

the rendering provider(s)

� Automate the transmit of CDS to the claims generation/revenue cycle management system

� For faxed (paper) orders:� Must include the CDS information on the “paper”

� The order intake system must be able to “ingest” the CDS information from the “paper” order

� Transmit the CDS to the claims generation/revenue cycle management system, either electronically or through some other means, i.e. print it on the diagnostic report to allow data entry into the RCM or billing system.

26

Our Recommendation

27

Current Status – Proposed MPFS Rule

� Appropriate Use Criteria: The AUC must be developed or endorsed by national medical societies or other “provider-led entities” and be evidence-based. � HHS will issue rules by 11/15/15 to designate AUCs

� Applications are expected to be submitted by 1/1/2016

� Approvals of AUC’s in expected June 2016 (approval good for 6 years)

� Qualified Decision Support Mechanisms: “We anticipate that the initial list of specified applicable CDS mechanisms will be published sometime after the CY 2017 PFS final rule” (Nov. 2016).

� Open Items still to be addressed: � Format and content of CDS Identifier/information to be submitted

with the claim.

� To whom (if anyone) can the ordering provider delegate the task of obtaining the ‘decision support identifier’?

32

Areas of Effort

� Dictionaries and Informatics: Work to establish

standard dictionaries for key data elements wherever

possible. Work with CDS vendors to provide this

information in a consistent fashion via a query of the

CDS number.

� The ONC has published suggested code set (RadLex) for

procedure codes.

Areas of Effort

� Mechanisms and Standards for Data Exchange: Working to determine the most efficient and least costly way to send and receive order information and reports

� As it turns out the standards for data exchange are interwoven into the IHE initiative.

� There is a need for a “one to many” connectivity solution. However, it is probably naive to there will be a single industry platform, rather it is expected that 2 to 4 vendors will emerge offering this connectivity. However, development will be dependent on data exchange standards.

Next Steps

32

IHE Profile Cycle Stages

MembershipStatus

Open Date Close Date Learn More

Call for Proposal Open July, 2014 30 Aug 2014 http://wiki.ihe.net/index.php?title=Radiology_Proposals_2012-2013

Proposal Selection Closedn/a

25 Oct 2014 http://wiki.ihe.net/index.php?title=Radiology

IHE Profiles drafted in IHE Committees

Closed Nov 12, 2014 15 Feb 2015 < ditto >

Public Comment Open 27 Feb 2015 27 March2015

http://www.ihe.net/Technical_Framework/public_comment.cfm

Trial Implementation Published

Open n/a

May2015 http://www.ihe.net/Technical_Framework/index.cfm

IHE Connectathon Registration

Open Aug 2015 Oct 2015 http://www.ihe.net/Connectathon/index.cfm

IHE NA Connectathon Dates

Open Jan 2016 Feb 2016 < ditto >

Dates are subject to change Please check wiki.ihe.net and click on Radiology

Thank you to Chris Lindop for this content

Get involved in the Connectathon!

� Interested vendors should attend a session to learn participation requirements for the January IHE Connectathon and the demonstration project at RSNA

� <> CPOE <> CDS <> RIS <> EHR <> Reporting <> Billing <> EDI <>

� August 4, 2015

� Led by Teri Sippel Schmidt

� Email Julie for the invite

Support our efforts with CMS!

� eOrdering members – please sign on to our latest

communication

� Join the eOrdering Coalition

� Communicate with CMS – comment on the proposed

annual rule

Help us improve!

� What are we missing?

� Who are we missing?

Thank YouCo-Chair:

Julie Pekarek, Merge Healthcare

Julie.pekarek@merge.com

262-912-3414

Co-Chair:

Steve Fischer, Consultant and CDI Emeritus

sffischer@cdirad.com

763.392.0266

Work Group Contacts