Most emergency physicians know that they need to document an indication for certain diagnostic tests for payment purposes. If not included with the order, either the radiologist has to infer it or contact the provider. In more recent years, the bar has been raised, especially for high dollar tests. PAMA codifies this process and allows Medicare (and other insurers) to deny payment. This is largely done via “black-box” computer algorithms without human interpretation. It’s easy to see why the American College of Radiology (ACR) jumped in to better define this process. So, as a provider-led entity, ACR came up with criteria to include definitions of 1) appropriate care, 2) may be appropriate care, 3) rarely appropriate care.

How Will AUC Consultation be Enforced?

Provider-led entities define the appropriate indications for every test, and if the ordering physician does not choose one of those indications, the software program will either refuse to order the test or require consultation. This is where CDS may help. For each test, there is a drop-down list of “appropriate” indications. However, implementing this is not so easy and may require accommodation by certain electronic medical records (EMRs). Ambulatory EMRs are ahead of this game while hospital-based EMRs are playing catch up.

In addition, the downside of using a predefined list, especially one developed by another specialty, is that it does not account for all scenarios and the “best” indication may not be present. ACEP has been working with the major vendors of the AUC’s to ensure that earlier frustrations with the lack of specific emergency medicine indications and parsing them into a separate and easily viewed list have been addressed. There is much more work to be done.

This is just one more example of where hospital EMRs fail to meet the needs of patients and clinicians. Workaround (eg, third-party software) solutions will be forth coming. In fact, ACR has created a solution for compliance—see “ACR Select.”

Potential Benefits of AUC

• The use of the CDS may provide information regarding utilization and, if evidence-based emergency medicine guidelines are used, it may aid the decision-making process.
• Five of ACEP’s 10 Choosing Wisely recommendations involve advanced imaging studies, and documenting more consistent practice and decreased cost may provide leverage regarding the need for other resources.
• Documenting consistent practice should allow us to demonstrate the value emergency medicine brings to patients and the quality sphere.
• When the outside primary care physician or specialist sends a patient to us for an advanced imaging study, the CDS may offer support for not having such tests performed in the emergency department.

Ongoing Concerns and Efforts

• • This requirement currently applies to advanced diagnostic imaging services defined as MRI, CT, nuclear medicine, and PET). ACEP should not support expansion to other studies.
  • This requirement has been delayed until at least January 2018, and should be further delayed due to a lack of widespread availability of suitable technology.

• While it may apply to the emergency department as a hospital “outpatient” department, EMCs are specifically excluded, and for good reason. Before implementing, hospitals must address the additional administrative overhead and the general lack of functional tools available within the EMR to make the use of CDS safe and effective for this purpose.
• One can argue the EMC exclusion, along with the types of studies to which this requirement applies, functionally eliminates this requirement for emergency departments. In the ED context, advanced diagnostic imaging services are never ordered on patient without a potentially serious medical condition (ie, EMTALA defined EMC). This is very different than other outpatient settings where routine non-emergency advanced diagnostic imaging services are most frequently ordered.
• There is no indication that the “black box” edits will do anything more than correlate the test ordered with an approved indication. Functionally, this means the ordering physician could choose any approved indication, whether or not it has a bearing on the actual reason for ordering the test. Whether the future will bring further scrutiny (eg, additional correlation with the test result or final diagnosis) remains to be seen.
• If this requirement is to be applied to the emergency department, only a well-designed functional established CDS that is integrated into the typical workflow (eg, integrated into the EMR) should be employed.

Many thanks to Todd Taylor, MD, FACEP, and J.T. Finnell, MD, FACEP for allowing us to use material from their article for ACEP’s Informatics Section Newsletter, March 2017.