Clinical Decision Support for Radiology

Day 1 – Open Discussions This slide set is split into two parts: Day 1 is very preliminary, just to promote discussion. The “Day 2” slides are beginning to firm up the direction of the profile.

Problem: CMS Mandate Jan 1, 2017 ( 25 months away ) Part 1 Consider the following image order under the new mandate but without any standards: Dr. Mary Smith, an internist, is reviewing a Patient Joe Jones, who is complaining of back pain. She opts to send Joe for an MR of the Lumbar Spine with contrast. Dr. Smith knows that she is supposed to use CDS for this imaging exam. Dr. Smith enters the order in her EMR. She then opens up a different application and re-enters the order information to get a CDS score. The score comes back low/inappropriate. Dr. Smith goes back into the EMR to look at the Joe’s chart to see if there is more information on his condition, and she looks at the CDS application to see if there is documentation of a more appropriate exam. Dr. Smith opts to stay with the current exam, but notes that it is with or without contrast. She gets a CDS score or number, then she has to go back into the order in the EMR to revise it, and then manually add the number.

Problem: CMS Mandate Jan 1, 2017 ( 25 months away ) Part 2 Consider the following image order under the new mandate but without any standards: She then faxes the order over to an imaging provider. The imaging provider, after receiving the faxed order and CDS verification code, manually inputs all of the order and CDS data and schedules the exam. Dr. Ann Andrews, a radiologist, protocols the exam and has concerns about aspects of it. She calls Dr. Smith to discuss. This information becomes a part of the radiology EMR, but does not populate back to the CDS system. The exam is performed, and the report created. At each step (Radiology EMR to transcription application to report), the CDS number has to be manually repeated. The report gets to the billing step, where the claim is halted because the CDS application used was not included. The biller calls the office of Dr. Smith to get more information to properly file the claim.

Scope 1.) Provide a method to “pass the baton” (ie., CDS code sequence/info) from device to device, similar to what is done today with other codes/data. (SWF.b) 2.) Provide method to interact with CDS decision support systems and retrieve CDS code given certain information. (dne, much larger than just radiology)

PCC CDS Profile to be balloted for (Nov 12 th ) New transactions (standards used) RadX-1 CDS evaluation request RadX-2 CDS evaluation response

SWF.b:

Other profiles affected? Charge Posting Post Acquisition Workflow? Teaching File and Clinical Export (TCE) – useful data to retain/analyze? Radiation Exposure Monitor (REM) – want to compare CDS code v. radiation exposure??? Code Mapping White paper

DAY 2: Directions set Nov 4 th, 2014 In Scope: Focus on transmittal/continuity of CDS data between systems (i.e., communicating the conclusion) Out of Scope: Method to query CDS system with indications and retrieve CDS data (including “CDS number”) This will be a new “CDS Communication” Profile: Too much to add to SWF.b and would add/change existing SWF.b actors For marketing and visibility purposes Track in Connectathon results Will focus on HL OMI messages

Use Cases CDS mechanism integrated into Order Placer “Manual” case – CDS mechanism stand alone portal. (Law requires a cost- free mechanism and AUC for referring physicians) Analyze data to look for “outliers” Order changes after CDS is obtained

CDS information CMS requires more than just a “CDS number”, in spite of the fact that terminology is fairly pervasive The CDS information may contain: Requested Procedure Code (Universal Service ID- provides alternative synonym) (*not required by CMS, may already be in order message, may be necessary to address n:1 issue) Which AUC (id/uid) was used, including version #. Issuer of AUC # - (there may be a certification number which may replace the id/version/mfg ) CDS mechanism certification # - id/uid, including version #, manufacturer of CDS (the certification number may replace the id/version/mfg ) Based on indications, is the outcome “met criteria”, “did not meet criteria”, or “criteria did not apply” CDS “decision support session id” of this use of the CDS and probably issuer of id

CDS related information- not specific to CDS The following data items do not need to be present in the order and may be added downstream National Provider (NPI) of ordering physician Payer Billing code (HL7 term?) –e.g., CPT/HCPCS The following data items will be present anyway: Order number (placer/filler) Other information to consider Alternate exam (procedure code) and its appropriateness result Indication coded for AUC system

Actors and Transactions Probably 3 Actors: Order Placer Department System Scheduler/Order Filler Claim Creator – “The system that is responsible for creating a claim for reimbursement, which requires the CDS information.” Transactions potentially affected: RAD-2 (Placer Order Mngt) RAD-3 (Filler Order Mngt) RAD-4 (Procedure Scheduled) – need to consider timing of transaction RAD-13 (Procedure Updated)

Relationship of CDS to Orders (ORMs) A single order (CT chest/abd/pelvis) may require using the CDS algorithm multiple times (1:n) It is probably possible (example?) for a CDS number to apply to multiple orders if a panel is ordered (n:1)

Issues Closed Issues: Will not map CDS information into DICOM objects (IOD, MWL, MPPS) since almost all reporting systems also receive ORMs We will disregard SWF.a profile (to be retired) This profile will not be dependent upon SWF.b Open Issues: Is it ok/better/disallowed to put the CDS info directly onto the report? How does radiology verify that the CDS information is valid and not just made up? Is HL7 working on CDS? (ask Tone Sutherland) – see Notes for HL7 wiki link to group May need to look at HL7 v.2.9 – would affect SWF.b How many systems still support HL7 prior to v.2.5 Talk to PCC – is ordering NPI in order placer message?

Notes Notes/future items to consider: Requested Procedure codes can be global (e.g., LOINC, RadLex Playbook) or can be a local code system (most common) – The CDS algorithm may have to map from a universal system to local codes. Or, the AUC procedure code may be different from the actual procedure code for imaging SNOMED is a possibility for indications coding, probably mapped ICD-10 is (will be) required by CMS for billing May need to use an HL7 Z segment for CDS information, if absolutely necessary Review DSS/OF Actor Definition Consider future ACR Registry interaction (but not for v1)

More notes: The “official” definition of a DSS/OF is: Manages the scheduling and performance of orders for diagnostic services (e.g., cardiology, radiology, cytology & anatomic pathology examinations, in vitro diagnostic testing) in a department or setting offering such services. Found here: ors_Rev1.0_ pdf ors_Rev1.0_ pdf There is an HL7 CDS Workgroup, more info found here: