Nearly every penny contributing to the cost of U.S. healthcare is the direct result of a provider decision. In their efforts to deliver the best care for their patients, clinicians sometimes overtreat, resulting in as much as $200 billion in annual waste.
The Protecting Access to Medicare Act (PAMA) aims to address waste and ensure evidence-based care for patients by requiring the use of clinical decision support (CDS) technology for the ordering of advanced diagnostic imaging services. CDS tools help determine if orders that are known to be overutilized are applicable to guidelines within a subset of clinical areas.
As a result of the COVID-19 pandemic, the Centers for Medicare & Medicaid Services (CMS) announced the extension of its PAMA compliance requirement, extending the testing period from year-end 2020 through 2021. CMS expects providers to use 2020 and 2021 to implement an effective, PAMA-compliant CDS solution that aids in ordering advanced imaging services, which include computed tomography, positron emission tomography, nuclear medicine and magnetic resonance imaging.
With the deadline extension, there are no payment consequences associated with PAMA compliance during calendar years 2020 and 2021. On Jan. 1, 2022, CMS will begin to withhold payment if proof of a CDS solution is not in place when ordering these services.
Meaningful CDS solutions guide providers with the latest care standards at the point of care.
Studies estimate that patient care is 112 times more effective when guidance is included in the provider workflow through a CDS solution. CDS is designed to influence provider behavior by helping guide clinicians with the latest care standards. When it comes to PAMA, CDS guidance should result in a higher quality of care at a lower cost for patients dealing with issues in one of eight clinical areas:
- Coronary artery disease (suspected or diagnosed)
- Suspected pulmonary embolism
- Headache (traumatic & non-traumatic)
- Hip pain
- Low back pain
- Shoulder pain (to include suspected rotator cuff injury)
- Cancer of the lung (primary or metastatic, suspected or diagnosed)
- Cervical or neck pain
Currently in use with more than 200,000 clinicians, Premier’s PAMA-compliant CDS offering, powered by Stanson Health, integrates with the electronic health record and determines a set of clinical details for the order being evaluated.
Based on these clinical details, one of the four following outcomes will occur.
- No guidelines apply: The PAMA mandate requires all advanced imaging orders be reviewed. However, the guidelines only target the eight clinical areas referenced above. If the order is for a clinical condition that is outside of one of these eight areas, the order will automatically be updated in the background to have an Appropriate Use Criteria (AUC) determination value of “No applicable AUC.” In this case, there will be no interruption in the provider’s workflow.
- The order adheres to guidelines: The order is automatically updated in the background to have an AUC determination value of “Adheres to AUC.” Similarly, there will be no interruption to the provider’s workflow.
- The order does not adhere to guidelines: A window will appear suggesting a different ordering action, for example, switching to a new, clinically appropriate order or canceling the original order.
- More information is required: A window will appear that will prompt for additional information. After it has been provided, clinicians will either be given a recommendation, or the order will be updated with the new AUC adherence determination.
To reduce errors, consider a solution that can extract detailed facts from chart data.
A strong tool for PAMA compliance has three key capabilities:
- Comprehensive clinical details based on documented chart data, which enables the solutions to retrieve comprehensive and accurate clinical details for an order. This yields stronger communication with radiologists, helps avoid overdiagnosis or overtreatment, and improves the overall quality of care.
- Accurate, applicable recommendations so that the clinician is more likely to follow and learn from the CDS presented. This should yield higher follow rates and greater reduction in unnecessary utilization.
- Seamless integration with EHR systems and data—helping to simplify both implementation and user experience with minimal disruption.
The intentions set forth under the PAMA requirements are commendable.
Clinicians need value-add tools that integrate easily into their workflow. Most importantly, technology should supplement their ability to drive improvements in care and lower costs for all.
With a PAMA solution successfully deployed, providers should see:
- Improved overall quality of care
- Reduction in unnecessary radiation and/or contrast exposure
- Availability of higher quality clinical histories for the radiologists
- Avoidance of overdiagnosis or overtreatment
Frustrated with your current PAMA solution? Connect with Premier’s PAMA experts today to talk about your transition.
We want to help during these tough financial times, so we are waiving all fees for the first year when you transition from a legacy solution. See our innovative solution in action. It’s helpful…not just required.