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K.0 Guideline Appropriate Ordering

The purpose of this implementation guide is to support communication of decision support guidance on whether or not an order is appropriate from EHR, hospital or departmental information systems, and enable receivers to validate that decision support was used to determine the appropriateness of those orders according to guidelines.

The Guideline Appropriate Ordering Profile supplies a mechanism by which EHR and departmental systems can evaluate orders to determine whether these orders conform to guidelines. The profile enables the results of the evaluation to be stored and transmitted, and the receiver of those results to verify that an order was evaluated with regard to appropriateness.

Under a new US law ¹ , starting in 2017, providers ordering imaging procedures must use physician approved appropriateness guidelines to reduce unnecessary imaging in patients for whom it is not appropriate. In order to be paid for Medicare outpatient care, facilities and physicians who perform certain imaging procedures (either the technical or the clinical component) have to be able to show that decision support was used in the ordering process ² . The European Society of Cardiology and the European Association of Cardiovascular Imaging have also identified a need for use of appropriateness criteria in cardiovascular imaging ³ .

K.0.1 Scope

This implementation guide is intended to support the use cases where a Clinical Decision Support is consulted during the processing of an order to ensure that the requested services are appropriate according to clinical guidelines at the time of order entry. It does not address orders proposed by a clinical decision support system because it is presumed that the CDS system has already ensured that any proposed service is clinically appropriate.

The focus of this guide is on ensuring that clinical decision support can be integrated into the ordering process. As far as this guide is concerned, the operation of CDS service itself is a black box. This guide does not specify how guidelines are selected during the evaluation, how the evaluation is performed, or the formats used to express the guidance in guidelines.

However, we are especially looking for feedback to ensure that this implementation guide is compatible withother mechanisms associated with clinical decision support, including CDS on FHIR. In particular, we are interested in comparing these two efforts, and understanding how to best provide CDS integration capabilities to EHR systems.

K.0.2 Conformance

This guide defines the following conformance statements. Systems implementing the actors described below should provide a conformance resource documenting their conformance to this implementation guide.

Actor	Description
GAO Decision Support Service	The Decision Support Service actor implements the $evaluate operation to determine whether that an order is appropriate according to clinical guidelines.
GAO Order Evaluation Requester	The Order Evaluation Requester actor invokes the $evaluate operation to determine whether an order is appropriate according to clinical guidelines.

K.0.3 Operations

This guide defines the following operations.

Operation	Description
GAO Evaluate Order	The evaluate operation examines an order, comparing it against known guidelines for appropriate use and returns the result of that evaluation to the caller.

K.0.4 Resource Profiles

This guide defines the following profiles.

Profile Name	Description
Guideline Appropriate Order	The Order resource references the request being evaluated (for diagnostic tests, medications, procedures, referrals), and is used to link the order details to the reason(s), date, patient and provider placing the order.
GAO Patient	The patient resource is required to provide relevant demographics associated with the patient. Other details may be provided according to local implementation requirements.
GAO Practitioner	The practitioner resource is required to identify the provider placing the order.
GAO Diagnostic Order	The diagnostic order resource is required to identify the diagnostic service or services that were ordered, and to provide additional details that may be necessary to evaluate the order for appropriateness.
GAO Referral Request	The referral request resource is required to identify the referral service or services that were ordered, and to provide additional details that may be necessary to evaluate the order for appropriateness.
GAO Medication Order	The medication prescription resource is required to identify the medications ordered, and to provide additional details that may be necessary to evaluate the order for appropriateness.
GAO Procedure Request	The procedure request resource is required to identify the procedures that were ordered, and to provide additional details that may be necessary to evaluate the order for appropriateness.
GAO Questionnaire	The Questionnaire resource is used to support an interactive question/answer implementation driven by the client. This interaction may result in a more favorable evaluation of the proposed order.
GAO Questionnaire Response	A QuestionnaireAnswers resource is used to answer questions that have been asked in order to determine the appropriateness of the order. A requester may pre-emptively provide answers to questions for orders it suspects may be necessary.
GAO Result	The result resource provides the result of the evaluation.
GAO Alternate	The alternate resource is used to reflect evaluations of alternate services that may be suggested by the decision support service.

K.0.5 Extensions

This guide defines the following extensions.

Extension	Description
GAO Score	Supports capture of evaluation score from the decision support system.
GAO Device	Supports identification of the decision support system used to evaluate the order.
GAO Guideline	Supports identification of the decision support system used to evaluate the order.
GAO Item	Supports identification of the decision support system used to evaluate the order.
GAO Period	Supports identification of the decision support system used to evaluate the order.
GAO Practitioner Identifier	Supports identification of the ordering practitioner.
GAO Signature	Supports identification of the decision support system used to evaluate the order.

K.0.6 Value Sets and Terminologies

This guide defines the following value sets and terminologies.

Name	Description
GAO Evaluation Result Codes	A set of codes which indicates the result of an evaluation of an order.
GAO Answer Format Codes	The set of question types allowed in a questionnaire used for evaluation of orders.

K.0.7 Resource

This guide provides the following examples.

Name	Description
Example GAO response parameters CT head outside of guidelines	A 50-year-old male is ordered a CT of the Head for his headache by an identified practitioner.
Example GAO response parameters CT head outside of guidelines with alternate	A 50-year-old male is ordered a CT of the Head for his headache by an identified practitioner.
Example GAO response parameters CT head no guidelines	A 50-year-old male is ordered a CT of the Head for his headache by an identified practitioner.
Example GAO request parameters MRI head	A 50-year-old male is ordered an MRI of the the Head for his headache by an identified practitioner.
Example GAO request CT head	A 50-year-old male is ordered a CT of the Head for his headache by an identified practitioner.
Example GAO practitioner	Identified Practitioner: 9999999999
Example GAO patient	A 50-year-old male.
Example GAO order	A 50-year-old male is ordered a CT of the Head for his headache by an identified practitioner.
Example GAO diagnosticorder head mri	Example GAO DiagnosticOrder for Head MRI
Example GAO diagnosticorder head ct	Example GAO DiagnosticOrder for Head CT

K.0.8 References

¹ H.R.4302. Protecting Access to Medicare Act of 2014. 03-JAN-15. Available on the web at http://www.gpo.gov/fdsys/pkg/BILLS-113hr4302enr/pdf/BILLS-113hr4302enr.pdf

² Burhmal, R. New Law Mandates Use of Imaging Appropriateness Criteria. RSNA. 01-JUN-14. Available on the web at http://rsna.org/NewsDetail.aspx?id=12360

³ Garbi, M et al. Appropriateness criteria for cardiovascular imaging use in heart failure: report of literature review. European Heart Journal – Cardiovascular Imaging (2015) 16, 147–153. 30-DEC-14. Available on the web at http://www.escardio.org/communities/EACVI/publications/Documents/EHJCI-appropriateness-criteria-garbi.pdf