A radiologist as gatekeeper is an unpopular position. No one wants to be told "no" when they ask for something. Radiology once had such a distinction as the gatekeepers of radiology imaging orders/requests. It is an inherently, though inadvertently, adversarial position. The radiologist is not the primary caregiver and therefore is typically less informed as to the clinical scenario at hand.

Recent decades have seen an explosion of imaging utilization, driving health care costs upward. In fact, radiology imaging has been so lucrative that non-radiologists bought their own scanners. As recently reported in the Journal of the American College of Radiology and by the United States Government Accountability Office, Medicare payments for radiology imaging, including MRI and CT scans, were higher to non-radiologists than radiologists between 2004 and 2010, a clear indicator that self-referral has driven imaging utilization.

This practice is not just done in the outpatient world. In hospitals, imaging has become commonplace for many symptoms to the point that the science, or evidence-based component, is absent in many cases.

Now, the American College of Radiology has finally produced a product called ACR Select, which can assist health-care providers manage expenses and care for their patients by integrating decision support with the order entry process. A passive gatekeeper, the program is designed to work with the electronic medical record (EMR) and electronic order entry process. 

The ACR has long produced Appropriateness Criteria, which are revised as often as necessary. These criteria are supposed to assist caregivers with their decision-making process when ordering tests such as CT scans and MRIs. The ACR Select product can be integrated into the EMR to provide a user-friendly method of access and education for the appropriateness criteria. As a result, providers can better identify when an imaging study is indicated based on the provided patient's symptoms.

How does it work? When a provider enters an order for an imaging study, a screen pops up on the workstation, with the relevant Appropriateness criteria for the specific clinical scenario. Appropriateness criteria ranks different studies in terms of appropriateness and level of radiation. The ordering physician can then choose the appropriate study, and can even choose references that substantiate the study being ordered.

ACR Select is a front-line gatekeeper that is designed to be a non-adversarial system component, integrated into the EMR, that assists ordering physicians to better meet their patients' needs. The role of radiologists is rapidly changing towards playing a more visible part in patient care. It is long in coming and should be embraced by the medical community as a help, not a hindrance. I applaud its development and hope that forward-thinking regulators and policy-makers see its obvious benefits.