Starting Jan. 1, 2020, Medicare is going to require proof that clinicians who order advanced imaging for their outpatients have consulted an approved appropriate use knowledge base as a prerequisite for the imaging provider to get reimbursed. Next year is a testing year, and potential penalties kick in the following January. Describing it as another flavor of pre-authorization, imaging informatics executives are working to make compliance easy for ordering providers who are not on the same electronic health record system.
During a recent webinar put on by the Society for Imaging Informatics in Medicine, Keith Hentel, M.D., executive vice chairman of the Department of Radiology at the New York-Presbyterian Hospital/Weill Cornell Medical Center, described his organization’s approach to getting ready for the Protecting Access to Medicare Act (PAMA) law going into effect in January.
Weill Cornell has 10 years of experience of integrating clinical decision support about appropriate imaging into its Epic enterprise EHR. It is a qualified provider-led entity under the PAMA program, which means it is allowed to create its own appropriate use criteria or endorse the criteria of others.
Hentel said the foundation of its approach to clinical decision support is the integration with Epic. Its approach is to apply clinical decision support to all patients, whether they are on Medicare or not.
The challenge with extending appropriate use criteria decision support to community providers is the diversity of systems involved. “Not everyone is within our electronic health record and not everyone is going to be submitting orders to us electronically,” Hentel said. “We still deal with a lot of paper and fax orders.” With January 2020 right around the corner, this is an issue everyone is going to be dealing with, he said, and it involves setting realistic goals.
“We have been working really hard to use appropriate use criteria to improve the value of care delivery and to eliminate exams that are not necessarily needed,” Hentel said. “Now in light of PAMA coming around the corner, we are minimizing our noble goal. Right now we are focusing on making sure all our business units comply with the requirements for PAMA.”
He said imaging executives have to ask themselves how they can make sure the decision support interaction takes place, the required codes are added to the Medicare claim, and that they have a copy of that decision support number if they get audited. It sounds like a lot of work, but Henzel describes it as just another flavor of pre-authorization. “We are used to making sure that we have a specific code associated with an imaging exam before we do it or otherwise we are not going to get paid. Commercial insurers have been doing this for years. In many ways, the appropriate use criteria program is better, because there is a lot more transparency and more rigor around how the rules are created that suggest and deny imaging. But when you distill it down, it really is pre-authorization all over again.”
So what is Weill Cornell’s overall strategy for dealing with orders that are coming from outside its EHR?
“The No. 1 thing is I want to make our clinical decision support solution easy to use for ordering providers that are going to be sending to us,” Henzel said. He emphasized that if his organization makes it cumbersome and somebody else makes something that is easy to use, referring physicians are not going to send their patients to Weill Cornell. “So it has to be easy to use and offer value to the patient and provider.”
Advantages of an Integrated Portal
Weill Cornell has both an integrated portal and a stand-alone web portal. In the integrated portal, the provider signs in and chooses the imaging exam they want to order. The clinical decision support fires just as it does in the core Epic EHR. They have to answer questions, and are given recommendations. They have the opportunity to change or cancel orders, or ignore the advice and go ahead with the order. It also offers them the ability to schedule the exam on behalf of the patient right after they go through the decision support, Henzel said.
The No. 1 advantage of the integrated portal is it reduces data entry, he explained. It also provides feedback reporting to ordering providers. “That is real value that as an imaging practice we can offer them,” he says. “They are going to need to know because they do not want to be labeled as outlying providers in the out years of the program and be subject to penalties for that.”
Another advantage of an integrated portal is that the decision support data is in the metadata so it can be transferred to billing systems without Weill Cornell having to retype anything. Although the organization has made it as easy as possible to sign up, adoption has been a challenge, Henzel said. “We have added one-click orders and tried to decrease data entry wherever possible. We have shown how it can decrease the number of phone calls, which is something that referring provider offices are generally in favor of. We can even provide access to reports and images through our stand-alone portal, making it an even more valuable tool. Still, adoption has been slow. But now that they are going to be required to do this, it is going to be a tipping point in driving people to use our integrated portal.”
For health systems working on an integrated portal, you have to work with IT to think about security and HIPAA and firewall sand credentialing, Henzel said. “You have to start curating your provider database because having a clean database and knowing who you have to reach out to is crucial.”
For old-fashioned physicians who do not want to sign up for an integrated portal, Weill Cornell is offering a stand-alone portal as well. The provider logs in, answers questions about the patient, generating a decision support number and an outcome. They can print it out or fax the paper. On the positive side, it is easy to use, and you don’t have to do much credentialing. There is no PHI involved. It is easy to implement. “The challenge is that there is a lot of duplicate data entry,” Henzel added. “It is pre-authorization-type work flow. You are going to generate a number and then it is going to be up to staff to make sure that number has been transmitted properly by the time the patient encounter happens.”
On the outpatient side, Henzel said, he is tempted not to use decision support for non-Medicare patients, “because in truth these offices have to go through standard pre-authorization in their workflow, and to make them go through the CMS appropriate use criteria and then go to preauthorization really seems like cruel and unusual punishment to me.”
