Optimizing Implementation of Clinical Decision Support with ACR Select for Advanced Imaging Studies

From the 2019 HVPAA National Conference

Dr. John Heymann (University of Texas Medical Branch)


With PAMA soon to be necessitating AUC consultation for Medicare reimbursement for advanced imaging studies, understanding how best to implement the various qCDSM programs available will be increasingly important. As clinicians already struggle with “click fatigue” qCDSM programs must be facile to use to engender provider buy in. Provider cultural buy in is necessary to achieve the goal of curtailing unnecessary imaging and better adhering to evidence based practice as opposed to simply improving appropriateness scores which can be gamed, such as by utilizing free text instead of a “structured indication” or choosing a structured indication known to give a score of Appropriate for a desired exam.


To facilitate implementation of ACR Select by optimizing user experience prior to providing feedback to clinicians. Specifically, to increase the utilization of structured indications (over free text) as well as to improve the appropriateness outcomes where structured indications are provided.


A monthly imaging stewardship pillar was convened to review monthly ACR Select Scorecards detailing institutional progress and to implement interventions to the physician interface prior to “turning on” feedback. Scorecard data was used to determine departments and exam types demonstrating the greatest opportunity for improvement. Various interventions aimed at optimizing clinician experience were implemented and a dashboard was created to track metrics, such as CT/MR per 1000 patient encounters for the institution or CT/MR per patient encounter for individual clinicians, in real time.


Over a 10 month period, the % score for green indications rose from 27% to 35%, the red indications dropped from 12% to 9% and the use of free text (unscoreable) exams dropped from 49% to 45% and steadily from a maximum high of 54% following an initial rise after implementation – before appropriateness feedback was provided to clinicians. These results reflect all studies across the institution and are more pronounced for the exams for which tailored changes were implemented.


Optimizing provider interface with qCDSM is important for provider buy in and can positively affect both utilization of structured indications AND appropriateness scoring without even providing feedback to clinicians.

Clinical Implications

The importance of reducing unnecessary medical imaging goes without saying: for decreasing socials costs, individual costs to the patient, decreased radiation exposure in the case of ionizing radiation, reducing potential anxiety, and allowing for more timely imaging and increased radiologist focus on medically necessary imaging among other reasons. While well intentioned and probably necessary, the implementation of the AUC requirement, particularly in the current climate of increasing regulations and click fatigue, runs the risk of seeing improvements on paper only as providers attempt an end run around the ultimate goal of actually reducing unnecessary imaging. The correct implementation of and ongoing maintenance of qCDSM programs will be paramount to creating all-in institutional cultures of quality to more effectively serve patient needs.

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