A large payer-provider collaborative initiative in Minnesota slowed growth in ambulatory orders of high-tech diagnostic imaging (HTDI), while also raising imaging appropriateness, through a pilot program using a standardized electronic decision support system, according to a study published in the August issue of The American Journal of Managed Care .
The results of the program bode well for physicians eager for an alternative to prior authorization and prior notification programs, which the state’s payers had begun adopting to cut costs associated with HTDI procedures (CT, MRI and PET), according to study authors Leif I. Solberg, MD, of HealthPartners Research Foundation in Minneapolis, and colleagues.
“This success reassured both provider groups and payers that we could do something about this challenge by working together,” they wrote. “All agreed that the best approach was to spread the point-of-order decision-support system, ideally through the normal channel of ordering important procedures, so that both clinicians and patients could learn and enhance shared decision making.”
Facilitated by the Institute for Clinical Systems Improvement, a regional quality improvement collaborative, a pilot program was conducted to test the effect of decision support systems at five large medical groups with more than 6,000 physicians. The point-of-care decision support system assigns a utility score from one to nine to procedures during the ordering process. Referring physicians can order a low-scoring procedure, but an alternative modality with a higher utility, or a suggestion not to image at all, is provided.
An audit of 300 randomly selected charts of patients with a head CT, head MRI or spine MRI was conducted before and after implementation of decision support to evaluate the impact of the program. Results showed an increase in the proportion of orders fitting appropriateness criteria from 79 percent to 89 percent. The authors noted, however, that there was no change in the frequency of positive findings or apparent impact on patients.
“The physician leaders of each pilot group reported that the use of decision support was much more efficient, patient-centered, and clinician supportive than having to call in orders for external review,” wrote Solberg and colleagues.
Utilization of imaging also began to level off around the time of the program’s implementation. There was a 20 percent and 36 percent drop in spine MRI and head CT orders, respectively, but no change in head MRI orders. HTDI orders overall plateaued, according to the authors, with an estimated savings of approximately $84 million from 2007 through 2009 compared with a scenario where the previous rate of increase had been sustained. Solberg and colleagues acknowledged that since prior notification programs were also still in use during this time, it’s difficult to isolate the effect of decision support alone, though comparisons with payers that never implemented prior notification indicate the plateau in utilization could have been sustained without much influence from the use of prior notification.
High physician acceptance of the pilot program led four nonprofit payers in the state to financially support the creation of a statewide implementation of the system. A common set of appropriateness criteria based on specialty association guidelines will be integrated within many EMRs, and clinics without an EMR can access the ordering system online. Aggregate data for the entire system will be used to refine the criteria and analyze the results of the broader decision support system.
“At this time, the contracts have all been signed with the payers, and both ordering and rendering provider groups are signing up. We expect that at least 80 percent of Minnesota physicians will be using this system within the next year,” wrote the authors.