When new Medicare requirements regarding outpatient imaging become effective in January 2020, the American College of Radiology (ACR) will have already established an impressive track record for helping clinicians prepare for the new protocol, which requires adherence to appropriate use criteria for approval and reimbursement for advanced imaging.
In 2015, the College unveiled the Radiology Support, Communication and Alignment Network (R-SCAN™), a step-by-step guide that connects radiologists and referring clinicians to improve the ordering of imaging exams that add value to patient care based upon a comprehensive list of imaging-related Choosing Wisely recommendations from a variety of specialty societies.
R-SCAN “was very timely, but the thing that prompted us was that the Choosing Wisely campaign published all those recommendations regarding imaging that fit with existing ACR Appropriateness Criteria,” said Max Wintermark, MD, Clinical Advisor for R-SCAN and a neuroradiologist at Stanford University. “We asked ourselves what kind of mechanism or process could we come up with that would allow us to increase awareness of the appropriateness criteria.” The ACR Appropriateness Criteria are evidence-based guidelines first introduced in the 1990s and now include 179 imaging topics.
Today, the use of R-SCAN for improving imaging orders helps clinicians prepare for the new federal requirement, under the Protecting Access to Medicare Act, that clinicians consult appropriate-use criteria (AUC) developed by a qualified provider-led entity, through a qualified clinical decision support (CDS) mechanism. This can occur either through a stand-alone, web-based tool or CDS software integrated into an electronic health record system. Clinicians must document the AUC consultation to receive payments.
Dr. Wintermark said that in conducting an R-SCAN project at Stanford, his team found excessive use of imaging, such as MRIs for lower back pain, that was attributable to a range of factors, including demand from patients and limited consultation time for physicians.
“It was not a problem that radiologists could solve alone. It really required a tight collaboration between the radiologists and the ordering physicians. That’s really the cornerstone of R-SCAN—the opportunity to discuss and to interact closely with our referring colleagues,” he said.
To support successful R-SCAN collaborations, the ACR developed educational activities that introduce referring clinicians to the appropriateness criteria and imaging CDS, including an imaging order simulation that tests knowledge of Choosing Wisely recommendations and appropriate-use guidelines. The activities also offer free continuing medical education.
ACR also makes available Choosing Wisely materials for referring clinicians to share with patients, and has a library of topic-specific materials on the R-SCAN website.
Jason Hom, MD, an internal medicine physician who has reviewed the educational materials as part of the R-SCAN team, said that as providers increasingly rely on technology in clinical decision-making, education tools will be critical in helping to guide evidence-based care.
“Case-based interactive simulation is a valuable way to engage providers because it’s more like real life. It’s more realistic, it’s more applicable than just something purely didactic,” said Dr. Hom. “If you go through a simulation as a provider it really makes you think about similar patients you have had and what you should do in a given situation.”
Podcasts offer another way of disseminating information, Dr. Hom said, adding that many of his peers listen to such broadcasts while commuting or at other times as a way to supplement CME or stay abreast of advances in clinical practice.
Dr. Hom acknowledged the well-known concept of alert fatigue, where clinicians are bombarded with so many CDS messages that it can be overwhelming, but added that in the case of high-stakes, high-cost imaging such as CT scans and MRIs, the benefits of well-designed and well-implemented CDS tools outweigh the downsides.
Dr. Hom also emphasized that patient education efforts such as the Choosing Wisely campaign will be equally, if not more, important with the new Medicare requirements on advanced imaging.
Patients can learn more about the appropriate use of imaging, including factors such as radiation exposure, incidental findings and unnecessary procedures. This can help patients understand why in some cases advanced testing isn’t indicated.
“We don’t want patients to leave thinking they got a raw deal. We want them to leave thinking that sometimes less is more,” said Dr. Hom.
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