1. The document discusses models for the successful deployment of clinical decision support (CDS) systems to ensure value in at-risk patient populations. 2. CDS has the potential to impact imaging utilization and costs when effectively integrated into healthcare workflows and championed by local physicians. 3. True utilization management requires coordinated efforts across people, technology, and processes to engage providers and ensure understanding and accountability.

1. Models for the Successful Deployment of CDS
to Ensure Value in At-Risk Populations
Daniel J. Durand, M.D.
Chair of Radiology and ACO Medical Director, LifeBridge Health

2. Relevant Disclosures
Advisor – National Decision Support Company
Panel member – American College of Radiology AUC
Disclosures

3. Experience:
‒ Little impact
Outcomes:
‒ Right test
‒ Radiation
avoidance
Cost:
– Deceased episodic cost (DRGs)
– Lower total cost of care (ACOs)
– Lower cost to patient (HDHCs)
Right test, Right patient, Right time…
Right in step with the Triple Aim

4. Volume world:
• Maximize billable transactions
• Imaging produces 35%+ of
health system margins
• Imaging feeds high margin
surgical service lines
• Emphasis on facility volume and
throughput
“Value” World:
• Get access to premium dollar
• Maximize “number of lives on
platform”
• Hit key quality metrics (e.g.
mammography screening %)
• Minimize overutilization of
high cost services
Fee for
service
Pay for
performance
Bundled
payments
Shared
savings
Capitated or
full-risk
Spectrum of contracting mechanisms
Risk
Imaging stewardship is a core
population health capability
National imaging CDS implementation
comes during a larger transition to value

5. What is CDS and how is it different
from existing payer processes?
Clinical Decision Support
Any form of automated, real-time feedback in response
to data entered by a clinician
“Prior authorization”
A process whereby referring physicians must receive
approval from an insurer prior to a test being performed
“Prior notification”
A process whereby referring physicians must notify an
insurer that they are ordering a test

6. What does the evidence say about the
impact of CDS on imaging utilization?
SOURCE: https://www.icsi.org/_asset/0g594t/HTDI-Decision-Support-Overview.pdf

7. Brief summary of evidence for and against
the efficacy of imaging CDS
• Early studies in the 1990s (Bates et al. at BWH) showed little impact
• Integration of ACR AUC scoring led to first major successful pilot (State
of Minnesota)
• Successful EHR integrations at MGH and VMMC in the 2000s
• Lackluster results from large-scale Medicare demonstration project
(possibly due to poor integration and lack of local ownership)
Data is mixed, but suggests that CDS can impact
utilization/cost when there are effective local champions

8. True utilization management requires the
“Golden Triangle” of transformation
People
Physician champions, preferably imaging stewards with
deep radiology expertise
Technology
CDS – the topic of most of today’s talks – may actually
be the easiest part of the greater change management
Process
Operational pathways to ensure understanding,
engagement, and accountability of ordering providers

9. Imaging workflow remains fragmented
and inefficient under fee for service
EHR
orders
RBM#1
RBM#2
No auth required
Medicare
Revenue cycle staff costing payers and providers at least
$10 per transaction

10. CDS can potentially be aligned to reduce
administrative burden
EHR
orders
RBM#1
RBM#2
Medicare FFS
Other entities
CDS
CDS will begin by bringing criteria to populations that are
currently “unmanaged” or “minimally managed”

11. (Some) core requirements for a “unified”
CDS population health solution
1. Can be deployed against a specific population in any ambulatory
or OP setting
2. Brings up-to-date consensus provider-led AUC to the point of care
3. Meets the workflow demands of providers
4. Meets the utilization management and/or total cost of care goals
of payers/ACOs/etc.
5. Allows for real-time data transfer and integration with other
downstream processes (e.g. care management pathways)
6. Does not preclude individual payers and providers to provide a
differentiated offering

12. CDS with integrated EHR / portal approach
allows for true population health mgmt
Local UM
process
Local UM
process
Central UM
process
AUC content can be accessed
through EHRs or web-portal
Additional UM oversight can be
administered locally or at payers
CDS can be seamlessly integrated
with other workflows, TPA, etc.
To CMS, TPA or
other vendors
EHR #1
EHR #2
NO EHR

13. CDS can potentially be aligned to reduce
administrative burden
EHR
orders
RBM#1
RBM#2
Medicare FFS
Other entities
CDS
Over time, it will make financial sense for some payers/ACOs to
either drop PA/PN or accept CDS as entry point to their process

14. Why I think the RBMs will either
integrate with CDS or go extinct
1. Because they should: Fragmenting workflow destroys value
and shifts costs
2. Risk is shifting to providers: Aligned providers are best
suited to establish appropriate imaging pathways
3. For payers (and some patients) unit price trumps
utilization: CDS can create a “just-in-time” trigger point for
value transparency
4. There will be a tipping point: As CDS becomes more
prevalent, the cost of RBMs to payers will increase while the
yield will decrease – eventually inverting ROI.

15. Entities most likely to embrace an
integrated approach to CDS and PA or PN
1. Medicare ACOs: Same population as Medicare FFS, thus
provides a mechanisms to recover FFS utilization “losses”
2. Medicaid and MA MCOs: Promising results from Maine Medcaid
3. Provider-owned employee plans: Often lack scale and are
unable or unwilling to outsource to RBMs
4. Large Self-Insured Employers: Increasingly looking for a way to
control costs without resorting to PA
5. Payers in geographies where RBMs have backfired or have
little traction: Recent example of Hawaii
Question for the group:
Is there a role for societies like the ACR to help organize and
facilitate CDS integration by payers?