“The greatest danger in times of turbulence is not the turbulence — it is to act with yesterday’s logic.” — Peter Drucker

This quote rings true for government-backed reform and regulation attempting to effect change in the era of technological disruption. The slow and contentious nature of the political process uses yesterday’s logic in times of rapid change brought forward by technological innovation.

So goes the story for the long-anticipated Appropriate Use Criteria (AUC) for advanced imaging, supported by the imaging community and the ACR. In the ideal world, imaging studies would be most appropriate for the clinical scenario, and the indication for such a study would be provided to the radiologist. Unfortunately, in modern healthcare neither of these consistently occurs. A myriad reasons exist for these deficiencies; however, one major barrier is a lack of knowledge by the ordering clinician on which study is best. The College has successfully embarked on a multi-decade campaign to provide easily accessible AUC (known as the ACR Appropriateness Criteria®) to ordering clinicians. These criteria allow a clinician to access expert opinion electronically on the best imaging study cataloged by clinical scenarios. The results of this query include the most appropriate exam type, if any, based on how multi-specialty experts rate each advanced imaging modality’s appropriateness. When followed, these criteria have the potential to reduce unnecessary imaging, streamline care, reduce costs, and electronically capture the indication for an advanced imaging study — making it available to the interpreting radiologist.

Congress, CMS, and most of the clinical community also supported using these AUC to the extent that they became part of federal law in the Protecting Access to Medicare Act of 2014. The law and subsequent regulations are not perfect, and in fact now suffer from technological disruption of yesterday’s logic. As the program currently stands, there is significant resistance to its implementation. The goal was to improve ordering exam appropriateness — obviating the need for other similar and arguably more arduous mechanisms, such as the radiology benefit manager’s prior authorization process. Unfortunately, the program is currently structured to require point-of-service recording of an appropriateness score for an advanced imaging study order. This adherence to obtaining a score would then be contemporaneously appended to every applicable CMS claim by the furnishing provider. The need to record and report a score for every claim submitted required an ordering clinician to interact with pop-up prompts from the AUC software for every advanced imaging study requested. This was an unwelcome disruption and frequent point of contention to the ordering-clinician community.

Technology, in the form of data registries, is beginning to define tomorrow’s path forward. Data registries have been used by CMS for outcome reporting in cardiac surgery since the early 1990s. Registry reporting exponentially grew under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which allowed most of medicine to report quality measures to CMS for the purpose of value-based payments. Registries allow for behind-the-scenes point-of-service data capture, data aggregation, performance benchmarking, and external reporting at intervals longer than a single event — making them ideal for data aggregation and individual trend tracking without the disruption of pop-ups inherent in the current design. They also serve as an educational tool, providing timely feedback to a referring clinician on performance for a specific topic set at intervals deemed acceptable by the using clinician. Most of the current software used to provide appropriateness feedback on an advanced imaging study can collect data in a registry format and can disable the point-of-service feedback (if requested). The College believes using these types of registries is a better path forward for the AUC program. Registries and retrospective feedback reports satisfy the College’s intent to foster learning opportunities for the ordering providers and improve overall imaging appropriateness — while still obviating the need for pre-certification. Operationally, using retrospective review would remove the furnishing provider from the liability of appending a CMS claim, with the adherence of the ordering provider consulting the AUC. With the July announcement that CMS will be delaying the penalty phase of the current AUC program “until further notice” beyond Jan. 1, 2023, the College believes this is an excellent opportunity to explore advocating for an AUC program of tomorrow, made possible by evolving technology. We just need Congress to listen.