Clinical Decision Support Mechanism

ARTIS® is an interactive computer program (electronic tool) used by clinicians (Ordering and Furnishing) that seek to consult with CMS approved Provider Led Entities (PLE), Appropriate Use Criteria (AUC). The primary purpose of the electronic digital consultation is to enable selection of the most appropriate diagnostic test(s) for a specific human disease(s) to rapidly allow for accurate patient diagnoses, precise patient treatment and higher quality patient disease management. This method is more effective and efficient than current methods. ATIS® can interface within a certified Electronic Health Record (HER), or can function as standalone independent program.

Unlike most CDSMs that derive their validity from either large date bases removed from local context, or academic institutions gold standards that may have little or no local applicability,  ARTIS® incorporates local hospital specific Appropriate Use Criteria (ACUs) developed through the Center of Excellence in Diagnosimetrics. Wye L., el al, University of Bristol, (view article) 2015 publication said it this way,

“Local information often trumped national evidence , academic research  or information from other localities.”

The process begins when ARTIS® is invoked by a clinician, and ARTIS® asks, if the clinician performed a clinical physical examination? This is an important first step, because ATRIS centers the primary care medical professional as the individual most capable to diagnose human disease. Septs 2 and 3, of the ARTIS process, capture the clinician’s artistic diagnostic expression. Step 2 asks if the clinician identifies and confirms patient’s symptoms, and step 3 asks if the clinician has associated patient’s symptomology to a set of provisional disease possibilities to be confirmed by a Center for Medicare and Medicaid Services (CMS), approved Diagnostic Appropriate Use Criteria (DAUC). ARTIS®’s ability to capture a clinician’s hunch, feeling that a patient has disease X is described by Hernandez, D., el al, (view article) in his seminal work as,

“Diagnosimetrics: The application of quantitative analysis to the art of disease diagnosis”

The embodiment of the process is illustrated in a flowchart (See Chart), with detail explanation of each step can be found below.

Step 1 Process Box 1-100 Initiates ATRIS® to ask Ordering Professional if a clinical physical examination was performed. If no is the answer, an interactive dropdown box requires an “x” be placed in a field box. The response is captured for future data analysis, and ARTIS® informs the ordering physician that a physical exam is required. If yes is the answer, an interactive dropdown box requires an “x” be placed in a field box, and ATRIS® continues to next step. As you will read in Boxes 2-300 and 3-100 the Ordering Professional orders the diagnostics test as explicated and required by CMS regulations.

Step 2 Process Box 1-200 ATRIS® asks Ordering Professional if identification and confirmation patient symptom(s) has occurred. If no is the answer, an interactive dropdown box requires an “x” be placed in a field box. The response is captured for future data analysis, and ARTIS® informs the ordering physician that a patient’s symptom(s) must be identified and confirmed prior to an order for a diagnostic test(s) as defined by the AUC. If yes is the answer, an interactive dropdown field box opens with fields (6 field boxes) to enter specific symptom(s), ARTIS field boxes are smart, and as you type in field Box 1, a human patient symptom as categorized in MERICK MANUAL of Patient Symptoms begin to appear. These each symptom have been assigned a unique identifier for future data analysis. The user has 5 more Boxes with same attributes. ATRIS® continues to next step.

Step 3 Process Box 1-300 ATRIS® asks if the Ordering Professional has associated a patient symptoms(s) to a disease(s). If no is the answer, an interactive dropdown box requires an “x” be placed in a field box. The response is captured for future data analysis, and ARTIS® informs the ordering physician that a disease diagnoses is required. As you will read in Boxes 2-300 and 3-100, the Ordering Professional orders the diagnostics test as explicated in the AUC, as required by regulations. If yes is the answer, an interactive dropdown box opens with fields (6 field boxes) to enter specific human disease(s), ARTIS field boxes are smart, and as you type in Box 1, patient human disease as categorized in 2017 ICD-10-CM begin to appear. Each disease (as many as six) are assigned a unique identifier by CMS 10-ICDM. ATRIS® associates the same DGR classification to the disease. These unique identifiers are captured for future data analysis. The user has 5 more field boxes with same attributes. Since a yes answer was provided, ATRIS® continues to next step.

Step 3 Process Box 1-400 ATRIS® asks if the Ordering Professional is ready to refer patient for diagnostic test(s). If no is the answer, an interactive dropdown window opens with 4 smart fields boxes. Each field box has a “grayed-out font” question that guides reader to the field box of choice. The grayed-out 4 questions are:
a) The first field box, asked the question, “Which applicable setting are you most likely to refer this patient?” As Ordering Professional initiates response, a drop box opens with referral options where location of local AUCs developed by the Center of Excellence in Diagnosimetrics (CED’s), Advisory Council, within a 25-miles radius from local applicable setting are populated. As Ordering Professional continues to type, and the applicable setting is not located within 25-mile radius, search is automatically increased to 50-miles. If ARTIS® does not recognize the applicable setting, an interactive dropdown window opens and directs attention to CMS approved PLEs, as published on CMS website, with web links to PLE’s webpage. Further, the dropdown window has ability to accept down loads from the PLE AUC webpage for all supporting AUC documentation.
b) The second Field Box, asks the question, “Would you like to view specific AUC associated with disease(s) identified in Box 1-300. The specific AUC associated for the specific location identified in Field Box 1-400 populates on the screen. Also available on the AUC window is an interactive button that when invoked presents the AUC supporting documentation as provided by CED’s Advisory Council (PLE application on file with CMS). When the AUC populates, if ARTIS® is connected to local facility patient schedule calendar, a box populates with patient time slots for the diagnostic test(s) associated with available time slots (for 90 days) and, if authority is granted, Ordering Professional may fill in patient appointment, or this task may be delegated. If appointment is made, and if ARTIS is connected to EHR, a certificate is generated by ARTIS® at time order is confirms. For each consultation, the applicability of imaging service ordered is documented as follows:

Certificate of Consultation
Certificate Number: 211712-1
Date of Consultation: 12-DEC-18
Time CDMS: 10:21 AM
Ordering Professional NPI number: 1111111111
Was locally developed ACU consulted: Yes
Was the service ordered incompliance
(adhere) with locally developed AUC? Yes
Locally developed AUC supporting
Documentation found on Local
Hospital website? Yes

Was an External AUC consulted? No

Was the service ordered incompliance
(adhere) with external developed AUC? Yes
If yes, see attached specific AUC,
or AUC developer’s weblink attached Yes

Was service ordered not in compliance
with either local or external AUC? Yes
Was specific AUC local or external
service ordered not applicable to
specific AUC to service ordered? Yes

Was service ordered have an
available AUC Yes
A note to the readerCMS reviewer:
Although, not required by regulations, for each diagnostic AUC (DAUC) and evaluative AUC (EAUC) test ordered, ARTIS records DAUC and EAUC test name and test results value as follows:
Positive means positive for disease identified in ARTIS® Flowchart 50, Box 1-300.
Negative means negative for disease identified in ARTIS® Flowchart 50 Box 1-300.
Equivocal means procedure resulted in suboptimal study. The suboptimal reason, i.e. patient movement, technical factors, schedule issue, i.e. patient had a barium procedure that made inadequate the AUC ordered. All of these data elements contained on the certification and ones not required, by regulation, are stored digitally for future analysis by Radiation Protection Associates (RPA), Division of Applied Research and Experimental Methods Design Development (AREM) Team.
Certificate is file in patient EHR, radiology sections with study report.
Additionally, the above certificate will be generated each time an ordering professional consults with a qualified AUC, and have a unique identifier generated by ARTIS®
c) The third Smart Box Filed 3 asks the question, “Would you like to review external approved DACU to local facility identified in Step 1-400?” If yes is the answer, ARTIS® presents all approved PLEs listed on CMS website. ARTIS® contains intelligent program language to search CMS web site quarterly to update internal stored approved PLE’s.
d) The last Smart Box Field 3 asks the question, “Would you like a consultation with Furnishing Professional prior to referral of patient to appropriate setting for diagnoses of disease identified in Filed Box 1-300?” Furnishing Professional(s) associated with disease(s) identified in Box 1-300 drops. Each associated Furnishing professional for CED’s AUC stored in the facilities local library is associated to each Furnishing Professional at the local facility for each specific DAUC and EAUC. Each Furnishing professionals’ email, office phone, cell phone, home phone, photograph and current work schedule (if available) populates. If ARTIS® has access and authority to Ordering Professionals’ calendar (outlook or others), ATRIS® may request an appointment. If the ordering professional computer is connected to the both Ordering and Furnishing professional phone line, ARTIS® can dial Furnishing’s phone if asked by invoking a button on the window displayed on the screen.

Step 4 Decision Box 2-100 is where ATRIS® provides a directional step to direct Ordering Professional based on responses generated in Step 3 Process Box 1-400. Either use local developed DAUC or use external CMS approved DAUC. If local DAUC is the decision, then proceed to Step 8 Box 3-100. If external DAUC is the decision, then proceed to Step 6 Process Box 2-200.

Step 5 Process Box 2-200 is how ARTIS® knows to make available external AUC—external to local facilities library of locally developed AUCs. The ATRIS® contains program language to visit CMS website to search for updated approved PLEs, and make available in “grayed-out” Field Box identified in Step 3 Process Box 1-400.

Step 6 Process Box 2-300 is how ARTIS® knows to provide consultation with Furnishing Professional. Based on responses in Step 3 Process Box 1-400, the ARTIS® contains program language to visit CMS website to search for updated approved PLEs, and make available in “grayed-out” Field Box identified 3 Process Box 1-400.

Step 6 Process Box 3-100 Patient arrives at applicable setting and presents prescription or clerk locates order in facilities order entry computer system.

Step 7 Process Box 3-200 is a detail Flowchart of (See Chart) of Box 3-100.

Step 8 Process Box 3-500 Test Results Send to Ordering Professional and ARTIS®

Step 9 Decision Box 4-100 is process step that confirms disease presence or not.

Step 10 Process Box 500-1 is process step where Ordering Professional may seek consultation with Furnishing Professional to discuss negative finding(s).

Step 11 Process Box 500-2 starts process over again.

Not part of ARTIS® program, but attained through policy AREM will adhere to the following:

Should a modification to an approved AUC be deemed necessary by CED’s Advisory Committee, CED will notify AREM and the local Standards Committee, not less than 1 Month post decision to modify specific AUC.

Protocol to remove potentially patient dangerous AUCs, or patients AUCs that are harmful if followed, is explicated below.

Policies
The Executive Director of the CED will notify AREM and all local facilities’ Standards Committees in writing when the CED Advisory Council either by way of applied research, or empirical discovery has knowledge that an approved AUC is potentially dangerous to patients and/or harmful if followed. The knowledge must be communicated no less than two days post confirmation by Advisory Council.

As CMS unrolls new priority clinical areas, EREM will develop new AUC(s) that address common and important clinical areas not later than three months post public posting by CMS.

AREM agrees to meet all privacy and security standards under applicable conditions under the law. This is achieved through standard forms employees of Radiation Protection must sign at employment initiation, and updated annually as part of corporate policy.

AREM, CED and Medical Diagnostic Physics Support Services (MDPS) will produce an annual comprehensive report that compares both diagnostic efficiencies and effectiveness, to include annual review of the local facilities diagnostic capacity. Additionally, Radiation Protection Associates will produce health system comparative performance reports annually. Lastly, members of the CED’s advisory committee communicate with local Standards Committee regularly, as needs present.

AREM agrees to maintain in electronic form storage of clinical, administrative, and demographic information on each unique consultation for a minimum of 6 years.

Comply with CMS modification(s) to any requirement under appropriate regulations pertinent CDSM within 12 months.

Notify all Ordering Professional of ARTIS® ruling within one month of CMS de-qualification as a Certified CDSM.