Can EHR Integration with CDS Tools Help Providers Show Compliance with Appropriate Use Criteria for Advanced Imaging Tests?

The PAMA (Protecting Access to Medicare Act 2014)  law signed by president Obama and passed in April 2014, mandates that physicians consult appropriate use criteria (AUC) before ordering advanced imaging tests. While originally intended for implementation on January 1, 2017, Medicare has postponed the implementation for now, but given the spiraling costs of healthcare, we can be certain that sooner or later providers will need to show that appropriate use criteria are met for advanced imaging tests.

The law further orders that physicians use appropriate clinical decision support mechanisms to demonstrate consultation with the Appropriate Use Clause. While there are many steps taken to make AUCs digestible and accessible like Harvard’s Library of Evidence (link:, the question we’ve been pondering here at Inferscience is, how will providers show compliance?  I see a few different ways.

EHRs could build AUC criteria into their patient workflow, so when the physician orders an advanced imaging test, the EHR would pull the appropriate data from the encounter and help them decide whether AUC are met or not. Alternatively the EHR could ask a series of questions to see if AUC are met. However, I see a couple challenges with this. EHRs do not have a great record on implementing – pardon the pun – meaningful clinical decision support. Most CDS built into EHRs I find to be either basic or irrelevant. Incorporating AUC will also require EHRs to build a large library of evidence based clinical rules. Again, most EHRs I have seen are not interested in providing this depth in content.

The physician could consult AUCs available from the major medical societies in the arcane language of Medicare, PLEs (Provider Led Entities). This would require  the physician to go to a website and either: read the AUC; or use some kind of interactive tool provided by the society whereby they manually enter the information and then decide whether the AUC are met. Depending on the test being ordered they may have to go to multiple society pages, to complicate things even further.

The third, and most likely to succeed in my opinion, is the use of third party apps integrated with EHRs with a library of the AUCs built into them. Such an application would leverage the power of EHR integration to extract the relevant clinical information from the patient chart and apply it against the AUC. The physician would find out whether the imaging test they ordered meets AUC without having to enter more data or spend time evaluating AUCs from multiple sources. Such an application would also provide documentation of how the decision was made and that the physician consulted the CDS, thereby meeting the requirements.

Inferscience’s Infera is a clinical decision support application that is capable of providing such functionality, and it is built to integrate with EHRs – reducing the burden on the physician to prove they’ve met AUC for advanced imaging tests.

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