from clinical guidelines to clinical decision support · from clinical guidelines to clinical...
TRANSCRIPT
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FROM CLINICAL GUIDELINES TO CLINICAL DECISION SUPPORT
Guy Frija, ESR Past-PresidenteHealth Forum, Athens, 12-14 May 2014
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NEED FOR GUIDELINES IN IMAGING
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WHY?
EUROPE: Euratom Directives and BSS
Mandatory establishment of clinical and technical guidelines
Umbrella of patient safety
Umbrella of EU citizens’rights: quality of care, patient mobility (cross-border healthcare directive)
USA: economic pressure
Explosion of the use of cross-sectional imaging
20 to 30% inappropriate tests
Side effects of incidental findings
Patient concerns about the risks of ionising radiation
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Dose Datamed 2,2013
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CLINICAL GUIDELINES
European survey by the ESR
Availability of RG (~ 70%)
Production: UK and France
Adapted and adopted: others
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OTHER REFERAL GUIDELINES
USA : ACR appropriatness
Australia : flow chart approach
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“ In Belgium we have referral guidelines; in fact, nobody really takes them into account ”…
“ Referral guidelines for diagnostic imaging in general are not in use in Hungary ”…
“ They are not used in the Netherlands ”…
“ Although we have several official referral guidelines published (in Spain), they are not used generally speaking ”…
“ In Italy the referral guidelines were published in 2004 by the Ministry of Health. Unfortunately they are not always followed
in clinical practice ”… “ There is no official guide line enforcement in the State service
in Ireland ”… “ In Germany, the guidelines are note routinely used ”…
“ In France, there are guidelines, but they are not used ”…
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CHANGE IN PARADIGM
Producing EB data
Increase EB practices
CDS
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WHY CDS?
Proven efficiency in the literature
Possibility to integrate into CPOE ,in the
physician workflow,and with the EHR
Patient centric, i.e. « personalised »
Adaptable to the practice setting
Scalable: focused or comprehensive
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CLINICAL GUIDELINES
Proven efficiency in the literature:No!
Possibility to integrate into CPOE ,in the
physician workflow,and with the EHR:No!
Patient centric, i.e. « personalised »:No!
Adaptable to the practice setting:No!
Scalable: focused or comprehensive:Yes
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ACR SELECT
NEW LEGAL REQUIREMENT IN THE USA
US House of Representatives passed the ‘Protecting Access to Medicare Act’, signed into law 1 April 2014
– Includes requirement for ordering physicians to consult appropriateness criteria before prescribing advanced imaging procedures for Medicare patients (from 1 January 2017)
– Applies to CT, MRI, NM and PET (not US and x-ray)
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WHAT IS A CDS?
• Decision support systems are a set computer-based tools that assist in some decision-making activity
• Designed to help resolve complicated problems and/or questions by supporting the decision-making process
• Especially valuable in situations where the amount of available information is prohibitive for the intuition of a human decision maker and where precision and optimal performance are of importance
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Decision support system
Konwledge Base DataBase
Inference Engine
Timely
CDS/CPOE
Point of Care DS
Clinical GuidelinesEHR/HIS/RIS
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Recommendations
• Based on clinical guidelines evidence-based and are regularly updated
• Accessible at the point of care. Real-time "clinical” Interface
• Diagnostic advice must be given in a probabilistic form
• Explanation and Justification accessible
• Must not attempt to replace the ”Doctor”
• Ability to override CDS guidance
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Select reason for examSearch enabled
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Select body area
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Select reason for exam
Select requested exam
Appropriateness information displayed
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Summary of exam selected
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ACRSelect – ACR Appropriateness CriteriaAC Scoring Table (>600 Original Documents)
Dr. Smith
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ACRSelect – ACR Appropriateness CriteriaACR evidence scoring of all reviewed literature (>5,000)
Dr. Smith
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ACRSelect – ACR Appropriateness CriteriaReferences to all reviewed literature (>5,000)
Dr. Smith
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ACRSelect – ACR Appropriateness CriteriaSummaries of Literature Review (>600 Original Documents)
Dr. Smith
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EUROPEAN CDS AND THE EC
DG’s: TRANSPORT,CONNECT,SANCO,RESEARCH
After 2 meetings:no funding available
Other organisations (IAEA,HERCA)
Proceed independently
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EUROPEAN CDS
Phase 1: merging RCR and SFR guidelines failed
Phase 2: open call for CDS tools
only 2 appropriate submissions
NDSC was considered most adequate
Phase 3: MOU with ACR for using Appropriateness Criteria
Phase 4: Europeanisation of ACR AC
Phase 5: ESR product (« iGuide ») with NDSC
Phase 6: ACR-ESR common set of guidelines
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BARCELONA PILOT PHASE
Independent pilot phase
Translation and coding adaptation (PWC)
without any difficulty
Initially targeted to GPs: very
welcome
Next expansion to emergency physicians
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MORE THAN A CDS
Common terminology:clinical indication and examens
-useful for benchmarking
Physician feedback: profiling
-useful for continuous improvement
Potentially integrable with structured reporting
-useful for increasing quality and reliability
-useful for datamining
Educational tool
- are you appropriate ? For residents training
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CLINICAL DECISION SUPPORT
Common Terminology
Clinical Decision Support
Structured Reporting
Data Mining
Continuous ImprovementPhysician Feedback: profiling
CDS as an educational tool
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ESR CDS:SUMMARY
Expected outcomes:decrease radiation exposure,increase health
quality and disparities,health economics,interoperability
Private-Private partnership :ESR-NDSC-ACR
ESR:not for profit scientific association-315 volunteers (pro bono),
62000 members,and 52 affiliate national Societies of radiology