Why Value-based Care Needs Clinical Decision Support Tools

December 08, 2015 - Ever since new legislation such as the Affordable Care Act or the Health Information Technology for Economic and Clinical Health (HITECH) Act were passed, the healthcare industry has been reforming and moving toward value-based care. There are a multitude of new technologies, innovations, and strategies for improving value-based care in the midst of the decline in fee-for-service payment models.

For example, clinical decision support tools have shown to have a big impact in helping improve advanced imaging protocols among physicians and help doctors support value-based care initiatives. To learn more about value-based healthcare payments and clinical decision support tools, HealthPayerIntelligence.com spoke with Ryan Lee, MD, MBA, Director of MRI, Director of Quality and Section Chief of Neuroradiology, in the Department of Radiology at Einstein Healthcare Network, and Brandon Long, Director of Radiology and Clinical Imaging at Cerner.

HealthPayerIntelligence.com: How exactly is clinical decision support helping doctors advance value-based care and improve imaging services?

Dr. Ryan Lee: “Clinical decision support is a great tool for clinicians ordering radiology studies. Previously, clinicians didn’t have any formal guidance. They basically had anecdotal evidence that they may have had in their specific experiences and perhaps conversations with their radiology colleagues. There was no formal way for them to really get appropriate guidance for ordering studies.”

“We see that problem all the time because not infrequently patients would show up with the wrong studies being ordered, necessitating   reordering of studies with new preauthorizations. With clinical decision support, this is will be changed.”

“The reason this is will be changed is because now the clinicians ordering the studies will have the standardized guidelines they have access to 24/7 based on criteria vetted by the American College of Radiology (ACR). They have access to a dictionary-worth of criteria at their disposal.”

“They enter in indications and the software will use the criteria that has been vetted and crunch out the most appropriate studies for whatever the indication is.”

HealthPayerIntelligence.com: Do clinical decision support tools assist in helping hospitals or clinics move toward alternative payment models like bundled payments? For example - do they eliminate the need for unnecessary tests or procedures?

Dr. Ryan Lee: “I don’t think clinical decision support does anything to move towards a specific model. We are moving away from a fee-for-service model in general towards a more value-based care model, but that’s not because of clinical decision support.”

“I think clinical decision support is that much more important in the value-based model because it eliminates waste. In the value-based model, waste is of high importance to eliminate. Clinical decision support allows a clinician to order the right test at the right time to minimize the wrong tests being ordered, and potentially even unnecessary tests.”

“I don’t think clinical decision support is leading us down the path of the value-based model. I think that path is already being steered toward the way legislation is being written, but it does help eliminate waste.”

“As I mentioned earlier, a clinician may order a study and there’s a good chance that the study he or she may order would be the incorrect study. The patient would show up for an examination and the best possible scenario is that the tech recognizes that there may be a problem, alerts the radiologist, the radiologist makes a phone call back to the office explaining that this isn’t the right study and a different study must be made. This generates a lot of extra work. That’s the best possible scenario.”

“The worst possible scenario is that the technologist doesn’t catch it, the incorrect study gets done, and the radiologist reads it and finds it doesn’t answer the question. It gets back to the referring clinician and the clinician after reading the study, says that a new study needs to be done to get a question answered. Another study has to be ordered, and the patient will have undergone two studies, one of which was unnecessary.”

“Had we caught it early enough, which clinical decision support can do, we could have eliminated that wrong study. That’s an example of how we can cut down on the waste by ordering the right study.”

“Potentially, we can also eliminate waste by controlling higher cost modalities and use clinical decision support to funnel some of the studies and convert them to less expensive studies, if appropriate. If an ultrasound may be more or equally as useful as a CAT scan, that’s an alternative that the clinician can choose and that’s exactly where the clinical decision software can steer the clinician towards.”

HealthPayerIntelligence.com: Does clinical decision support help move the healthcare industry away from the fee-for-service payment model? In what ways?

Dr. Ryan Lee: “Clinical decision support doesn’t move us away from fee-for-service, but it is an excellent tool to have particularly in a value-based model. Clinical decision support actually has utility in both models, but it has additional benefit because the waste that we’re eliminating is even more important from a cost perspective in the value-based model. For hospital networks to survive in the future in a value-based model, they can’t afford to have all these extra studies ordered because they’re going to be eating the cost.”

“Again, clinical decision support is pushing us towards that model. We are heading that way because of the way the legislation is written. The impetus is for organizations to form ACOs and get bigger in order to capture more patients. The more patients they have, the more they can spread their cost and capture more of the market that way. That’s why we’re seeing lots of mergers of institutions across the country. We are certainly seeing that in Philadelphia.”

HealthPayerIntelligence.com: Do you believe that, if the budget reconciliation bill becomes law, there will no longer be a push toward value-based payments?

Dr. Ryan Lee: “It doesn’t change the fact that we are eventually going towards a predominantly value-based model. I think that much is clear.  Most hospital networks are positioning themselves assuming that.”

“Legislation is even being written for clinical decision support to mandate physicians who are regularly not following the recommendations of clinical decision support to be penalized.”

“All those models point to the fact that value-based purchasing is definitely here to stay. I doubt that the bill would change anything regarding us going back towards a fee-for-service model, but time will tell.”

HealthPayerIntelligence.com: Do you have any final thoughts on value-based care and clinical decision support?

Dr. Ryan Lee: “I’m very excited about using clinical decision support. I think a lot of us are because, from a radiologist point of view, it’s very frustrating to read studies that don’t answer the question and which necessitate calling patients back for the right study. I think eliminating that kind of waste – no matter what sort of payment model we’re in – is definitely a good thing.”

Brandon Long: “Clinical decision support can improve access to care.  One aspect is that right now, we have radiology benefit managers who sit in the middle of the ordering physician and the radiologist. I think this is a very administrative burden and has a lot of waste in the system such that an ordering provider who wants a hi-tech imaging exam must get the proper authorization to do so.”

“Sometimes this may take several days if not weeks. That in and of itself is preventing access to care. There are some states who have moved away from prior authorization from radiology benefit managers due to the successes of clinical decision support. I think this is going to provide better quality at a lower cost but it is also going to provide better access through removal of administrative waste in the system.”

“From an electronic medical record perspective, our vision is to get the radiologist back in the center of the care team. Yes, there are laws that are pushing us to do this and there are definitely some cost/quality considerations, but ultimately these are the type of solutions that are getting the radiologist back in the center of the care team. We are excited to support these new technologies.”