Beginning in January 2020, the Centers for Medicare & Medicaid Services (CMS) will require healthcare providers to consult appropriate use criteria through a qualified decision support mechanism before ordering advanced diagnostic imaging tests for Medicare patients.1 It is part of an effort to avoid unwarranted testing and the unnecessary use of medical resources while also promoting the most appropriate care for patients.

The Johns Hopkins University Department of Medicine reports that it has been designated by CMS as one of 22 institutions engaged in developing criteria for when tests, such as CT scans, MRI scans, and nuclear imaging, should be ordered in the ED or other ambulatory care settings.

Johns Hopkins Health System (JHHS) has made strides in this area. In 2018, its High Value Care Committee implemented interventions aimed at encouraging the appropriate use of both lab and imaging tests, a move that resulted in more than $4 million in reduced hospital charges to both payers and patients at Johns Hopkins Hospital, according to reports from the JHHS. Further, JHHS is part of the High Value Practice Academic Alliance, a consortium of more than 90 academic medical centers in the United States and Canada working to advance high-value medical practices. Health system teams at JHHS already have established criteria to guide their own diagnostic decision-making. They have embedded the criteria into the electronic medical record (EMR) systems used by hospitals and ambulatory practices in the health system. To date, more than 70 guidelines addressing both diagnosis and management of clinical scenarios have been integrated into the EMRs used by EDs within the JHHS. Health system analysts report that the effort has resulted in care that is more consistent with the criteria.

As a “qualified provider-led entity” for the CMS Appropriate Use Criteria Program, Johns Hopkins will focus on developing criteria in eight clinical priority areas: chest pain, pulmonary embolism, neck pain, low back pain, shoulder pain, hip pain, headache, and lung cancer.

Johns Hopkins experts plan to make the criteria available to all other healthcare providers by the beginning of next year when the new appropriate use criteria requirements for advanced diagnostic tests kick in.

REFERENCE

  1. Centers for Medicare & Medicaid Services. Medicare Learning Network fact sheet: Appropriate use criteria for advanced diagnostic imaging. December 2018. Available at: https://go.cms.gov/2UomYCZ.