The Role of Imaging Decision Support in Value-Based Care

In this article

As an actively practicing radiologist with experience across diverse integrated health systems, from military medicine to large accountable care organizations, I have seen firsthand how inappropriately ordered imaging impacts patients, providers and the financial sustainability of early value-based care models.

My journey with clinical decision support (CDS) began with implementing early systems, and I’ve experienced both successes and challenges that shaped my understanding of effective adoption. I have also been actively involved with the American College of Radiology (ACR) in various capacities, helping to transition appropriateness guidelines from publication to the point of care.

This is a unique strength of CareSelect® Imaging, an EHR-integrated solution that brings the ACR’s Appropriateness Criteria® — the recognized gold standard in evidence-based imaging guidelines — directly to the point of order.

Value beyond PAMA

While early adoption of imaging CDS was driven primarily by regulatory compliance, particularly the Protecting Access to Medicare Act (PAMA), these solutions deliver value far beyond regulatory requirements through enhanced clinical decision-making and improved patient outcomes across all care settings.

As healthcare continues to evolve toward value-based models and financial risk shifts to providers and health systems, these tools become increasingly crucial for appropriate resource utilization while maintaining high-quality patient care.

I've witnessed the scope of imaging appropriateness extend well past the outpatient Medicare population initially targeted by PAMA. Non-Medicare populations and diverse clinical environments show equally compelling needs for CDS, for instance:

Inpatient settings, where inappropriate or delayed imaging can significantly extend length of stay
Emergency departments (EDs), where rapid decision-making is critical, yet challenging
Pediatric care, where radiation protection is especially important for developing bodies

A recent study published in Emergency Radiology, the Journal of the American Society of Emergency Radiology, found that the rate of over-ordering resulting in inappropriate imaging studies in the ED can be as high as nearly 60 percent. Further, appropriately ordered imaging was 3 times more likely to yield findings compatible with the initial diagnosis.¹

Ensuring appropriate utilization in complex clinical scenarios

Pediatric populations represent a particularly critical area for imaging CDS. Research by Dr. Brij Bhushan Thukral highlights the unique challenges in pediatric settings, where appropriate imaging requires balancing diagnostic needs against long-term radiation concerns.² Studies have shown that pediatric advanced imaging CDS offers benefits in reducing unnecessary radiation exposure to this vulnerable population.³ Unlike with adults, pediatric imaging appropriateness must account for developmental considerations, different disease patterns and heightened radiation sensitivity.

In inpatient settings, where each unnecessary day adds significant costs and increases a patient’s exposure to hospital-acquired conditions, CDS solutions can deliver tangible benefits. Hospitalist teams using these tools can avoid redundant studies, select the optimal modality initially and prioritize urgent cases. CDS helps optimize limited imaging resources by supporting appropriate utilization across all care settings, balancing urgency with clinical necessity.

Reducing the prior authorization burden with CareSelect Imaging

Beyond these clinical benefits, organizations can reduce administrative burden through payer agreements that recognize the consistent application of evidence-based guidelines. Healthcare organizations that regularly demonstrate high-quality appropriate use documentation may qualify for streamlined prior authorization processes or "gold card" status with certain payers, generating substantial administrative savings while maintaining quality standards. This benefits patients, payers and providers alike by saving time and money while ensuring patients receive the right test at the right time.

A large academic medical center in the Midwest provides a compelling example of these benefits in action. They instituted a prior authorization gold card program using CareSelect Imaging to reduce costs, expedite care, and improve ordering behavior. By coordinating with payers to use CareSelect Imaging scores for advanced imaging studies, they automatically approved high-utility orders.

This resulted in an estimated $250,000 in savings from one insurance provider alone and one full-time employee due to reduced pre-authorization work. Most importantly, imaging exams were scheduled and performed sooner instead of waiting days for authorization, helping to expedite patient care. As they noted, "This has been a win-win for patients, the payer and for us. Patients have faster access to care, and time and money is saved by bypassing the traditional prior authorization process."

The bottom line

Imaging CDS is not just a compliance tool but a fundamental component of high-quality, cost-effective healthcare delivery. Even with the Centers for Medicare & Medicaid Services pause on PAMA, solutions like CareSelect Imaging continue to provide significant value as healthcare organizations shift toward value-based programs. By leveraging comprehensive CDS tools, hospitals and health systems will be better positioned to thrive in risk-bearing payment models while delivering superior patient care.

About Greg Mogel, MD, FACR

Greg Mogel, Physician Advisor for CareSelect at Optum, is a radiologist and physician executive with expertise in clinical decision support and healthcare AI, especially in value-based care settings. A former USC professor and military veteran, he holds appointments at UCSF and University of Hawaii.