September 01, 2010
Clinical decision support tools such as computerized order entry systems could significantly reduce the number of inappropriate scans ordered by referring physicians, new research shows
Researchers at Massachusetts General Hospital (MGH) in Boston found that an electronic system that prevents nurses or office assistants from ordering low-yield CT, nuclear medicine scans or MR imaging drastically reduced the rate of such exams and markedly increased the percentage of tests personally ordered by physicians, according to a study published in the June issue of Radiology.
Similarly, an analysis of the appropriateness of outpatient CT and MR imaging referred from primary care clinics showed that approximately 26 percent of exams do not meet appropriateness criteria and subsequently yield negative results, according to researchers at the University of Washington's Harborview Medical Center in Seattle. Results show the advantage for referring physicians to adopt newly emerging clinical decision support systems, according to the research published in the March 2010 issue of the Journal of the American College of Radiology.
"Hard Stop" Software Proves Effective
In 2004, MGH began using a nine-point scoring system for outpatient electronic order entry, based on American College of Radiology (ACR) appropriateness criteria ranking imaging exams for diagnostic usefulness. Three years later, the facility modified the system to include the hard stop on red (HSOR) function, an electronic ordering system that requires on-call physicians to authorize advanced imaging studies that scored 1-3 points on the ACR scale.
Researchers who compared 76,000 orders taken between April 2007 and December 2007 with the new system in place against approximately 43,000 orders from the same period in 2006 uncovered dramatic results, according to Vartan M. Vartanians, M.D., lead author of the study and a clinical research associate in the Department of Radiology at MGH.
"Before we implemented this change, almost 75 percent of the exams were ordered by nonclinicians," Dr. Vartanians said. "Afterward, about 54 percent of these were initiated by clinicians, for an increase of about 28 percent."
Results showed a decrease from 5.43 percent to 1.92 percent in the fraction of low-yield CT, nuclear medicine exams and MR imaging performed, while the probability of cancellation of the exam increased by 3.5-fold after the policy change, Dr. Vartanians said.
The Web-based software features advantages including offering the physician suggestions for a better exam in the event of a low score or inappropriate exam. "There is still the need for the clinician to decide which exam is better, which will increase the appropriateness of the exam and provide feedback, so it also has educational value," Dr. Vartanians said.
"Another plus is that feedback is real-time," he continued. "And clinical judgment always prevails. If the physician thinks the exam is appropriate, he or she can order it even if the system shows a lower score."
Physicians Need Better Decision Support Tools
Although the University of Washington (UW) study revealed a high number of inappropriate imaging exams, the results "may be more
Although revealing, those numbers could be somewhat misleading. "Even though we show that about 25 percent of radiology studies are inappropriate, the actual number is lower because we don't imply that all these exams would not be done," said Dr. Bree, a professor of radiology at UW and attending radiologist at Harborview Medical Center in Seattle. "They may also be modified to an alternative. Examples from the study include MR imaging of the spine, which is not recommended for acute back pain prior to conservative therapy. Similarly, CT scans of the brain to evaluate a headache are also not recommended. In some cases, an MR might be a better choice than a CT scan at the outset, avoiding duplication."
The study also validates the evidence-based guidelines, since there were statistically significant outcome differences between appropriate and inappropriate examinations with 58 percent of the appropriate group having positive results that affected patient management.
"Some doctors know they are overutilizing imaging exams—something they attribute to legal risks," Dr. Bree continued. "On the other hand, sometimes they truly don't know when to request an exam or which test to order. That was the hidden message in our paper—that there's a really high need for education among primary care doctors. We need better tools to help them."
Although reducing the number of requested exams stands to impact the role of radiologists, there is a way to offset that factor, according to Dr. Bree.
"Currently, our payment systems are set up so that the treating physician decides what exam is done," Dr. Bree said. "Radiologists should be more involved in making that decision. In the past, radiologists have been the doctor's doctor. We should strive to become one of the patient's doctors and be compensated for our consultative expertise."
Learn More
The study, "Increasing the Appropriateness of Outpatient Imaging: Effects of a Barrier to Ordering Low-Yield Examinations," in the June 2010 issue of Radiology, is available here. An abstract of the study, "A Prior Authorization Program of a Radiology Benefits Management Company and How It Has Affected Utilization of Advanced Diagnostic Imaging," in the March 2010 issue of the Journal of the American College of Radiology, is available here.
Appropriateness Criteria Focus of RSNA Session
The Special Interest Session: "The ACR Appropriateness Criteria—Are You Trying to Tell Me What to Do?" will be offered Monday, Nov. 29 at RSNA 2010. Registration for RSNA 2010 is under way at RSNA.org/register