Raising The Bar In Imaging Stewardship: Electronic Determination Of Appropriate Patient And Exam Selection

From the 2022 HVPA National Conference

Davis Rogers MD (Johns Hopkins Hospital), Suresh Nayar MD, Brandyn Lau MPH, MD, Uma Srikumaran MD, Robert Sterling MD, Pamela Johnson MD, Lee Riley MD, Franco Verde MD, Alex Johnsons MD, Katie Lobner MILS, Adam Levin MD


Effective January 2022, CMS requires medical providers to consult appropriate use criteria (AUC) delivered by clinical decision support mechanism (CDSM) in the electronic medical record (EMR) when ordering advanced imaging (CT, MRI, Nuclear Medicine) in 8 Priority Clinical Areas (PCA). To focus on the PCAs with high caliber evidence, our institution became a CMS-approved Qualified Provider Led Entity (QPLE) in 2019 designated to develop AUCs, which are integrated into the EMR.


While use of a CDSM obviates prior authorization for Medicare patients, many commercial payers require traditional prior authorization processes for advanced imaging. Accordingly, our AUCs were designed to (1) ensure the most efficacious imaging test for the suspected condition and (2) confirm that a patients’ presentation reflects a reasonable likelihood of the pathology.
Described here is the evidence identified in the literature and rules for MRI orders in patients with hip and shoulder pain. This report focuses on common MRI indications in the ambulatory setting: suspected rotator cuff or SLAP injury in patients with shoulder pain, and suspected labral tear, femoral acetabular impingement (FAI), and ischiofemoral impingement in patients with hip pain.


Multiple literature searches from 1990 to present were performed by an informationist in conjunction with subject specialists to identify research investigations, systematic reviews, meta-analyses, and clinical practice guidelines evaluating the utility of MRI in patients with shoulder pain or hip pain. Results from the search were screened in duplicate by two radiologists, followed by the same process for full text review. From each publication, one or more rules about imaging appropriateness and patient selection criteria were extracted into evidence tables. Each publication was graded using Oxford Centre for Evidence Based Medicine Levels of Evidence. A multispecialty physician team used the evidence to design exam and patient selection criteria.


For shoulder pain, review of 1497 publications identified 53 articles; the hip pain review of 408 publications identified 15 articles. Strong evidence supports MRI for diagnosis of the 4 conditions (Figures 1,2). However, high caliber studies identifying reliable physical exam findings were lacking. Accordingly, available evidence and consensus clinical expertise were synthesized to define patient selection criteria for each condition (Figures 3,4). The CDSM collects information about the suspected condition and the patient’s clinical findings, and determines whether the order is consistent with our rules. Feedback is provided at the point of care (Figure 5) to assist providers in identifying patients who will benefit from an MRI.


Physicians can demonstrate accountability for judicious use of advanced imaging and facilitate the prior authorization process by integrating evidence-based patient selection requirements into CDSMs and documenting medical necessity. Collaboration between radiologists and non-radiology specialists is necessary for the design of patient selection rules.

Clinical Implications

Clinical decision support tools with appropriate use and medical necessity criteria play an important role in guiding best practice with respect to patient selection for advanced imaging. Next steps include analysis of MRI diagnostic yield to validate the patient selection criteria, as well as a comparison of the CDSM approval determination to current standard of care.

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