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 high quality 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 are applicable to guidelines within a subset of clinical areas known to be overutilized.
The Centers for Medicare & Medicaid Services (CMS) expects providers to use 2020 to prepare to have an effective, PAMA-compliant CDS solution in place that aids in ordering these advanced imaging services, which include computed tomography (CT), positron emission tomography (PET), nuclear medicine and magnetic resonance imaging (MRI).
While 2020 is considered a preparatory and educational year, on January 1, 2021, CMS will begin withholding payment if proof of a qualified CDS solution is not in place when ordering these advanced diagnostic imaging services.
Meaningful CDS solutions obtain comprehensive clinical details for an order to efficiently and effectively guide providers 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 them 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, which include:
- 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
Premier’s PAMA-compliant CDS offering, powered by Stanson Health, reads available information from the electronic health record (EHR) 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 of 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 of 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 very detailed facts from chart data.
This is what enables CDS solutions to retrieve comprehensive and accurate clinical details for an order. A strong tool for PAMA compliance has three key capabilities.
- 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 total unnecessary utilization.
- An avoidance of dependence on indication selection to ensure an ever-increasing ability to evaluate an order with zero input from a provider. Focusing on clinical areas where there is stronger evidence for imaging usage (priority clinical areas) results in less total workflow disruption to providers.
- Comprehensive clinical details based on documented chart data improves communication with and is more useful to radiologists.
The intentions set forth under the PAMA requirements are commendable. Clinicians need tools that are as least disruptive as possible while integrating into their workflow to supplement their ability to drive improvements in care and lower costs for all.
Learn more about Premier’s CDS solution, powered by Stanson Health, to see how we’re helping clinicians prepare for PAMA or request a demo.