Local, State, Federal

Imaging e-Ordering Coalition Successfully Makes Case to Congress

Scott Cowsill

Radiology benefit management (RBM) companies are no longer the only option in Washington for managing advanced imaging utilization. The Imaging e-Ordering Coalition has successfully convinced Congress to include computer-based physician order entry (CPOE) solutions as a potential method for imaging utilization management in recently passed health care legislation. However, the Coalition still has many challenges ahead to make CPOE as widely accepted as RBMs.

The Washington-based e-Ordering Coalition—a grassroots coalition of electronic clinical decision support companies and radiology organizations—was born out of the original health care budget legislation, which specifically referenced RBMs as the way to manage imaging utilization. That line item got the attention of Scott Cowsill, senior product manager for the diagnostic solutions division of Nuance Healthcare, Burlington, Mass, and Liz Quam, director, Center for Diagnostic Imaging Institute, Minneapolis.

Cowsill, now cochair of the Coalition, said that organization’s long-term objective was to eliminate the RBM mention in the legislation, or at least to have language that gives providers an option to use clinical decision support.

After gaining support from other companies and organizations, including the ACR, Cowsill and Quam made trips to Washington to educate legislators about the CPOE option. Cowsill reported that upon meeting legislators, he was surprised by their positive reaction. “One person said, ‘This is what we’ve been looking for. We just didn’t know that it existed,’ and they were specifically referring to clinical decision support for HITECH diagnostic imaging. They thought that the RBM model was really their only option,” Cowsill said.

To help make their case, Cowsill and Quam cited regional studies showing the benefit of imaging-related CPOE with decision support, most notably a Massachusetts General Hospital study that was published in Radiology.1

While the legislators were swayed enough to remove the specific RBM language in the final Patient Protection and Affordable Care Act (PPACA), the e-Ordering Coalition still has a great deal of work ahead. It must not only gain more private and public payor support for CPOE, but it must also show more national data to prove CPOE’s clinical and cost effectiveness in reducing the utilization rate.

One program that will provide national data is a pilot CPOE project funded by the Medicare Improvements for Patients and Providers Act (MIPPA). The pilot will implement advanced diagnostic imaging CPOE in different markets across the United States.

In addition, the Center for Innovation, a new entity under CMS that was created as part of the health care reform bill, will study how to vary payment to physicians who order advanced imaging tests based on established appropriateness criteria, such as the ACR’s. Currently, CMS is not utilizing any RBMs or CPOE systems.

For now, the Coalition is making several recommendations to policy makers in Congress and CMS. One of the recommendations is that imaging CPOE tools should be based on consensus medical guidelines and literature, such as the ACR’s appropriateness criteria. Another recommendation is that CPOE and decision support tools should be compatible with any CMS-approved electronic medical record (EMR) systems and be able to track results.

Cowsill, who comes from a family of physicians, strongly believes that any CPOE tool should be simple to use and be incorporated into a physician’s clinical workflow. CPOE tools can do that by being incorporated into EMRs. In addition, they can help educate physicians about the latest evidence-based criteria for ordering diagnostic tests.

“Our objective isn’t just to say, ‘No, we don’t want you to do as many high-tech diagnostic imaging studies,’ but to educate ordering physicians so they’re ordering the right test the first time for that patient,” Cowsill said.

As part of their awareness and education campaign about CPOE systems, one of the e-Ordering Coalition’s next steps is to build a Web site with guidance and information on how to negotiate with insurers and successfully implement CPOE into physician practices. Cowsill hopes the Web site will be completed and live sometime by the end of 2010.

Tor Valenza


  1. Sistrom CL, Dang PA, Weilburg JB, Dreyer KJ, Rosenthal DI, Thrall JH. Effect of computerized order entry with integrated decision support on the growth of outpatient procedure volumes: seven-year time series analysis. Radiology. 2009;251:147-155.