Speed of Care Decision Support Client: Advocate Health Care
For Advocate Health Care, a 12-hospital system in the Chicago area, Speed of Care Decision Support currently provides product management, application programming, and IT support for a custom referral software application used daily by 4,200 physicians and staff. To ease the burden of manually approving as many as 2000 referrals/day, the application approves most referrals automatically based on hospital-configurable rules. Referrals requiring pre-authorization are routed to Advocate staff for manual review and approval. We extended the capability of the referral process by developing a clinical decision support tool to assess appropriate use for each referral. Also configurable, Advocate has developed Appropriate User Criteria for 48 different services to date.
Since its deployment, the referral system has processed close to 4 million referrals, 20% of which required an AUC consult. While the number of consults tripled, the percentage of referrals requiring pre-authorization dropped 14%. This system is an example of using technology to achieve the Institute for Healthcare Improvement’s triple aim. It improved population health by recommending the appropriate care based on evidence-based guidelines, improved the patient experience by expediting referral authorization, and reduced costs by eliminating unnecessary services. The application was awarded 2nd Place for Technology for the Improvement of Administrative Efficiency at the Emerging Technologies and Healthcare Congress.
PAMA Clinical Decision Support for Radiology
Clinical decision support (CDS) for radiology is a set of evidence-based guidelines that assist ordering providers in making the most appropriate imaging or treatment decision for a specific clinical condition. The guidelines, known as “Appropriate Use Criteria” (AUC), evaluate the requested procedure and the clinical indications (or contra-indications) to determine the best procedure.
The Protecting Access to Medicare Act of 2014 (2016-26668.pdf ) states that in the future, physicians ordering advanced diagnostic imaging exams (CT, MRI, nuclear medicine and PET) must consult evidence-based appropriate-use criteria through a CDS system that has been approved by the Centers for Medicare and Medicaid Services (CMS). Non-compliance will result in the withholding of payment unless the ordering provider can prove that CDS was used in the claim.
What You Need to Know
Radiologists should start communicating with their referring physicians to ensure that they are aware of the PAMA mandate for clinical decision support (CDS) for advanced imaging. Referring physicians should become familiar with the available CDS vendor options approved by CMS. CMS announced the list of qualified decision support mechanisms (software tools) that meet the provisions of the PAMA mandate.
Speed of Care offers a CMS approved CDS solution for radiologists and ordering providers. Click here to learn more.
- Ordering professional places an order for an imaging procedure (CT, MR, NM, PET)
- The CDS software evaluates the clinical condition and imaging service to determine appropriateness. It may suggest a list of alternate procedures. This evaluation generates a CDS-consultation number for the order.
- Ordering professional accepts the suggested change to the order, or declines it and moves forward with current order
- Radiology reviews order. Accepts order and adds protocols to order
- Exam performed and completed
- Claim submitted for payment using the CDS-consultation number
Articles About the CMS PAMA Mandate