Preparing for the Delayed - But Still Coming - PAMA Mandate for Radiology Clinical Decision Support

It’s unfortunate, but not a major surprise, that the CMS recently postponed its PAMA mandate for hospitals and imaging centers stipulating that radiology clinical decision support (CDS) systems must be in place by January 1, 2017. Ideally, the new deadline will not extend into 2018.

This mandate is not the first to be delayed. Like Meaningful Use and ICD-10 before it, the radiology CDS mandate will come.  And radiology practices need to prepare for it - now. 


Is inappropriate imaging a problem?  Does clinical decision support (CDS) work in reducing it?

Dozens of articles clearly document the size of the problem associated with the inappropriate ordering of medical images.  Figure 1 highlights data from the June, 2010 issue of the Journal of the American College of Radiology (JACR) article titled “Analysis of Appropriateness of Outpatient CT and MRI Referred From Primary Care Clinics at an Academic Medical Center: How Critical Is the Need for Improved Decision Support?”

Figure 1. Lehnhert BE, Bree RL. JACR 2010; 7:192-197.

Figure 1. Lehnhert BE, Bree RL. JACR 2010; 7:192-197.

An article published in a JACR the following year shows that CDS significantly helps in addressing the challenges associated inappropriateness. See Figure 2.

Figure 2. Blackmore CC, Mecklenburg RS, Kaplan GS. JACR 2011; 8:19-25.

Figure 2. Blackmore CC, Mecklenburg RS, Kaplan GS. JACR 2011; 8:19-25.


How will the use of clinical decision support impact radiology practices?

CDS works.  And despite the delayed mandate, CDS will soon be a reality for hospital and imaging center radiology practices.  With this reality come significant changes to these practices.

The mandate requires that CDS must be used for CT, MRI, and Nuclear Medicine studies (including PET) – specifically for non-emergency Medicare outpatients.  Once a CDS has been installed for this group, it’s logical that the organization will use it for all patients.

Whether or not ordering doctors follow CDS guidelines is a major question that comes to mind. According to the mandate, they will not be required to do so.  However, the mandate states that up to five percent of ‘outliers’ will need to use pre-authorizations on their patients by 2020, making it likely that CDS proposed guidelines will  be followed. 

Let’s say that proposed guidelines aren’t used.  Nothing will change, right? In reality, the volume of ordered imaging studies may decrease due to the ‘hassle factor’ of using a poorly-designed CDS system – but not necessarily in the best interest of the patient.  This was recently demonstrated when a radiology benefit management firm reported volume reductions despite no denials.  So assuming guidelines will be followed to at least some extent, practices need to develop an understanding of how deep reductions will be, and tools and mechanisms exist that will provide that analysis. 

As ordering via CDS systems becomes part of routine physician workflow, significant shifts will occur.  For example, fewer MRIs may be done or a large number of CTs could be replaced with ultrasound.  These changes would have a major impact on capital equipment acquisition staffing and other operational decision. 

No two radiology practices are alike, so it’s impossible to predict the exact changes that will occur at a specific hospital or imaging center.  Opportunity exists, however, for these organizations to analyze their own data to help in having a better understanding of shifting metrics

Sophisticated tools exist, such as MedCurrent Impact™, that analyze incoming orders to determine the shift in orders that would occur when a future CDS system would be present. Making the assumption that these same physicians will follow CDS recommendations in the future, one could secure a better estimate of how many fewer studies are likely to be done (by modality) while also learning about specific shifts that will happen across various modalities.    In addition, one could estimate the financial impact of the CDS system.  Armed with this knowledge, a practice has a reasonable chance of how to prepare for forthcoming repercussions of the mandate.

Despite the radiology industry’s delay with the PAMA mandate, financial and operational leaders should get an early start on understanding the implications associated with it.  Ample opportunity exist now for individual practices to get ahead of a situation that is sure to impact both operational and financial management.