Preparing for the delayed — but still coming — PAMA mandate for radiology clinical decision support

By Herman S

It’s unfortunate, but not a major surprise, that the CMS recently postponed its PAMA mandate for hospitals and imaging centers stipulating that radiology clinical decision support (CDS) systems must be in place by Jan.1, 2017. Ideally, the new deadline will not extend into 2018.

This mandate is not the first to be delayed. Like Meaningful Use and ICD-10 before it, the radiology CDS mandate will come and radiology practices need to prepare for it—now.

Is inappropriate imaging a problem? Does clinical decision support (CDS) work in reducing it?

Dozens of articles clearly document the size of the problem associated with the inappropriate ordering of medical images. A 2010 issue of the Journal of the American College of Radiology (JACR) contains an article titled, “Analysis of Appropriateness of Outpatient CT and MRI Referred from Primary Care Clinics at an Academic Medical Center: How Critical Is the Need for Improved Decision Support?”, that highlights data on this issue. Based on clinical indications the article suggests, for instance, that 62% of head CT scans are inappropriate, as are 53% of spine CTs.1 Another article, also published in the JACR the following year, showed that CDS significantly helped in addressing the high rate of inappropriate studies. The performance of head MRI for “headache” dropped 23% after introducing CDS with a drop of 23% is use of MRI “back pain” as well.2

How will the use of clinical decision support impact radiology practices?

Clearly, CDS works and, despite the delayed mandate, CDS will soon be a reality for hospital and imaging center radiology practices. With the implementation of CDS potentially comes significant changes to these practices. The mandate requires that CDS must be used for CT, MRI, and Nuclear Medicine studies (including PET), specifically for non-emergency Medicare outpatients. Once a CDS has been installed for this study group, it’s logical that the organization will ultimately apply its use for all patients.

Whether ordering doctors follow CDS guidelines remains a major question. According to the mandate, they will not be required to do so. However, the mandate states that by 2020 up to 5% of ‘outliers’ will need to obtain pre-authorizations for indications outside the guidelines making it likely that the CDS proposed guidelines will be followed.

Let’s speculate that the proposed guidelines are not used. Nothing will change, right? In reality, the volume of ordered imaging studies may decrease due to the “hassle factor” of using a poorly designed CDS system, but not necessarily in the patients’ best interests. Recently a radiology benefit management firm reported volume reductions despite no denials. So assuming that guidelines will be followed, to at least some extent, practices need to consider the impact on volume that could occur. Today, tools and mechanisms exist to provide this analysis.3

As CDS-guided ordering becomes part of routine physician workflow, significant shifts will occur. For example, fewer MRIs may be done or a large number of CTs could be replaced with ultrasound. These changes would have major impact on capital equipment acquisition, staffing and other operational decisions.

No two radiology practices are alike, so it’s impossible to predict the exact changes that will occur at a specific hospital or imaging center. Opportunity exists, however, for these organizations to analyze their own data to help improve understanding of their anticipated shifting metrics

Sophisticated tools, such as MedCurrent Impact™3, help analyze incoming study requests and compare them to requests mostly likely to be made if a CDS were in place. This approach helps track study shifts to secure a better estimate of how many studies are likely to be done post CDS (by modality) while also getting knowledge of specific changes that will happen across modalities. In addition, one could estimate the financial impact of the CDS system. Armed with this knowledge, a practice has a better chance to more fully prepare for the repercussions of the mandate.

Despite the radiology industry’s delay with the PAMA mandate, financial and operational leaders should get an early start on understanding the implications associated with it. Ample opportunity exists now for individual practices to get ahead of a situation that is sure to impact both operational and financial management.


  1. Lehnert BE, Bree RL. Analysis of appropriateness of outpatient CT and MRI referred from primary care clinics at an academic medical center: How critical is the need for improved decision support? JACR. 2010;7:192-197.
  2. Blackmore CC, Mecklenburg RS, Kaplan GS. Effectiveness of clinical decision support in controlling inappropriate imaging. JACR. 2011;8:19-25.
Herman S. (Jan 07, 2016). Preparing for the delayed — but still coming — PAMA mandate for radiology clinical decision support. Appl Radiol. 2016; 45(1):6-8.
Dr. Herman is an Associate Professor at the University of Toronto Faculty of Medicine and a practicing radiologist at the University Health Network in Toronto. He is also Chief Executive Officer for MedCurrent, a Toronto-based provider of clinical decision support (CDS) solutions.
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