Clinical Decision Support: Standardized Processes for 2017 Deadlines. Background and Steps Forward

Transcription

1 Clinical Decision Support: Standardized Processes for 2017 Deadlines Background and Steps Forward

2 Disclosure Liz Quam, Executive Director, CDI Quality Institute Julie Pekarek, VP Solutions Management, Merge Healthcare

3 Learning Objectives During this session, attendees will: Understand the background to the CDS legislation and the Protecting Access to Medicare Act of 2014 and its impact on imaging Learn about the current initiatives underway to help set up a smoother implementation Discuss with peers the options available to work on this initiative

4 Clinical Decision Support (CDS) Why and What is It? A Clinical Decision Support tool is an alternative to prior authorization and helps physicians identify the most appropriate imaging study based on the clinical indications, in real time. Built on evidence-based data sets developed by national specialty society medical guidelines, e.g., research, peer reviewed literature, consensus At the point-of-order and in real time 4 Copyright 2015 Merge Healthcare

5 The History: Diagnostic Imaging Costs and Quality High growth rates from led Congress and CMS to enact steep cuts in reimbursement an unsustainable solution for life a saving technology. 5

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7 Since his first budget in 2008, the president has included a recommendation for Medicare to develop a prior authorization process for advanced imaging. This includes his 2015 budget. Major effort to keep mandate for prior authorization out of Affordable Care Act -Medicare does not have an appeal-of-denials process currently -Two types of CDS: the other one is crabby doc syndrome Major effort with each SGR patch to block prior authorization as a pay for 7

8 Pre-Authorization a Big Challenge Percentage of Imaging Programs Investing in Preauthorization Percentage of Programs Using Model as Primary Method of Obtaining Preauthorization 1% 8% 20% 12% Don't Know Yes 46% 18% Clinical Decision Support 3rd Party Outsourcing Imaging Program Ownership 68% No 27% Hospital-Wide Centralization Referring Physician Retained Finance Function Contributing to Denials Weekly Time Spent on Preauthorization Process with Health Plans Mean Hours per Physician, by Nurses and Clerical Staff % 19% Other Preauth Nurses Clinical Staff Primary Care Medical Specialty Surgical Specialty Source: The Advisory Board Company 8 Copyright 2015 Merge Healthcare

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10 Administrative Cost Savings Calling RBM vendor: 1,850 orders/month x 10 minutes/order = minutes or 308 hours. CDS imbedded inside EMR: 1,850 x 10 seconds = 5 hours/month. Total savings every month was 303 hours or 18,000-24,000/year in salary/benefits Barry A. Bershow, M.D. Former Medical Director, Quality & Informatics Fairview Health Services Minneapolis, MN 10

11 Impact of CDS at Brigham and Womens Hospital (BWH) Work Group on a Standard Imaging Order 11

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13 Clinical Decision Support (CDS) U.S.: Protecting Access to Medicare Act of 2014 Medicare Sustainable Growth Rate (SGR) reauthorized to control Medicare spending on physician services ( doc fix ) Delayed ICD-10 codes for diagnoses Mandated the use of a Clinical Decision Support tool (Mechanism) in the ordering of every Medicare Outpatient CT, MRI, Nuclear Medicine, and PET study performed in the country (Section 218) The attending physician orders the exam, but it is the radiologist who will not be reimbursed if the attending does not use CDS for the order 13 Beginning January 1, 2017 Copyright 2015 Merge Healthcare

15 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, Ordering professionals identified as outliers versus their peers will be subject to prior-authorization beginning on January 1, 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) 15

16 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 16

17 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 address, method of contact (phone, , 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 17

18 The Life of an Order 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. Physicia n/staff ENTER INFO SAVE Physicia n/staff Physician SIGN SUBMIT Physician Hospital or SCHEDUL imaging ctre CLINIICAL REVIEW Radiologi st Imaging Center/ Third party PRE- AUTHORIZE CREATE REPORT Radiologi st Fax, HL7 DELIVER REPORT 18

19 Imaging Orders Electronic Requisition HL7 19

20 The Typical Imaging Order Paper Requisition 20

21 The Final Step CMS electronic or paper claim 21

22 Evidence-Based Medicine Cycle Patient-Specific Clinical Indicators Identified in EMR or CPOE Patient-Specific Appropriateness Scores Returned Order Placed Order Imaging Procedure Requested by Physician Request Procedur e Procedure Conducted Improved Care, Lower Costs Ordering Feedback Received by Physician Incremental Rule Developed Clinical Outcomes Analyzed Analytics Reviewed If: then 22

23 CMS Reiterated its Intention to Implement CDS 2016 Proposed Rule: Confirmed CMS intention to implement January 1, 2017 Primary focus on establishing rules surrounding which evidenced-based data sets Did not address claims filing issues writing: We anticipate including further discussion and adopting policies regarding claims-based reporting requirements in the CY 2017 and CY 2018 rulemaking cycles. 23 Copyright 2015 Merge Healthcare

24 Ordering Physician Requirements Consult the CDS tool and document the consultation U.S. Statute reads as follows: The mechanism generates and provides to the ordering professional [information]... that documents that the qualified clinical decision support mechanism was consulted by the ordering professional. Ordering Provider is required to provide information to the rendering provider (radiologist) to file their claim for having performed and interpreted the imaging exam 24 Copyright 2015 Merge Healthcare

25 Imaging Facility and Interpreting Physician Requirements U.S.: Payment for such service may only be made if the (radiologist s) claim includes the following: Which clinical decision support mechanism was consulted by the ordering provider The NPI of the ordering provider; and Whether the service ordered would o o o Adhere, Would not adhere, or Whether such criteria was not applicable If this information, or its proxy, is not on the facility s or the interpreting physician s claim the, payment will be denied 25 Copyright 2015 Merge Healthcare

26 Goal: Standardize the CDS Information Flow We looked to IHE to develop the standard the roadmap we need - to support a smooth vendor implementation IHE PCC s Guideline Appropriate Ordering (GAO) & Radiology s CDS-OAT profiles 26 Copyright 2015 Merge Healthcare

27 IHE Profile Cycle Stages Membership Status Open Date Close Date Learn More Call for Proposal Open July, Aug le=radiology_proposals_ Proposal Selection IHE Profiles drafted in IHE Committees Closed n/a Closed Nov 12, 2014 Public Comment Open 27 Feb March Oct le=radiology 15 Feb 2015 < ditto > amework/public_comment.cfm Trial Implementation Published IHE Connectathon Registration IHE NA Connectathon Dates Open n/a May amework/index.cfm Open Aug 2015 Oct on/index.cfm Open Jan 2016 Feb 2016 < ditto > Thank you to Chris Lindop for this content Dates are subject to change Please check wiki.ihe.net and click on Radiology 27

28 Current IHE status Patient Care Coordination Proposal (PCC) Was submitted to and accepted by the IHE nical_decision_support_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 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

29 Standards-Based Solution CPOE Patient Care Coordination IHE Profile Scope Interaction with Decision Support AUC #1 AUC #2 AUC #3 AUC #n Decision Support Mechanism Radiology IT IHE Profile Scope Fax Radiology InformSyste m Billing System CMS Communication of Decision Support 29

31 Next Steps Several eordering Coalition members joined together and offered to serve as a resource to CMS regarding how the CDS documentation travels with the orderto-claim: AHRA, ACC, ACR, AQI, CDI, MedCurrent, Medicalis, Merge, RBMA*, RadNet, vrad *leading the coalition

32 Benefits of Decision Support & Discussion/Questions Enables real-time decision support Provides iterative education for providers Reduces patient exposure to unnecessary radiation Documents the appropriateness of the care Drives quality up and costs down Reduces rescheduling of scans Improves patient flow/clinic efficiencies Supports provider/patient relationship Promotes consultation between radiologist and ordering provider Helps meet meaningful use requirements 32