IMAGING INFORMATICS: IHE RADIOLOGY ORDER ENTRY

CLINICAL DECISION SUPPORT

Based on the RSNA 2014 presentation, December 2014

Written by: David S. Mendelson, M.D.

Professor of Radiology

Senior Associate- Clinical Informatics

The Mount Sinai Medical Center

Co-chair IHE International Board

Adapted and presented for the IHE Colombia IHE

Workshop by:

Elliot B. Sloane, PhD, CCE, FHIMSS

Co-chair IHE International Board

President, Center for Healthcare Information

Research and Policy (CHIRP)

Radiology Orders

The right order The right reason for

exam and background information

Automated scheduling

Pre-defined Procedure steps at the modality

Uniformity of exam

Radiology Order Entry Clinical Decision Support

Standard Exam dictionary RADLEX Playbook

Modality Worklist Standard Protocols

mapped to a modality RADLEX Playbook Series pre-defined

What do we need? Enablers

Radiology Orders

Appropriateness Cost Control

Radiology Order Entry Clinical Decision Support Ensure the correct order based upon

standardized rule sets Utilization control

Inappropriate Utilization Redundant Imaging

Replacement for Radiology Benefit Managers

Education for the clinician Compare their ordering metrics to their

peers

Inappropriate Utilization

Defensive Medicine – Liability concern Tort Reform

Patient Demand Financial Incentives

Self referral Pressures to minimize overall cost of an episode of

care Physician lack of knowledge Duplicate exams

Results not easily available Patient lack of understanding of exams already

performed Fragmented care – no coordination of care

Up to 20% of imaging exams may be inappropriate

Iglehart JK. Health Insurers and Medical-Imaging Policy — A Work in Progress. N Engl J Med 2009;360:1030-1037

A Roadmap for National Action onClinical Decision Support-June 13, 2006

Decision Support

Collegial advice Text references Web sites Computer systems

Passive Active

Alerts Reminders Corollary Orders Guidelines

Clinical Decision Support Systems (CDSS or CDS)

Incorporates Patient data (EHR) Rules Engine Medical Knowledge

Produces a patient specific recommendation

Clinical Decision Support - CDS CDS is a technology that may help to

significantly improve the appropriateness of orders through dissemination of Comparative Effectiveness Research (CER) to clinicians at the point of order-entry.

American College of Radiology Appropriateness Criteria (ACR AC) A formal mechanism to determine the

utility of imaging exams to diagnose disease

Evaluate existing evidence comparing candidate modalitites

Synthesize a utility index Rand/UCLA Appropriateness method

Evidence Consensus

Limitation – evidence is generally not on double blinded randomized studies

Radiology Benefit Managers RBM services to obtain pre-clearance

for high cost procedures Effectively Diminish Utilization

Issues Burden of a frustrating time consuming

solution with a significant cost in manpower

Implementation Is this done rationally?

CDS- some data

Pilot study in Minnesota with members of Institute for Clinical Systems Improvement (ICSI)

Imaging growth was curbed while simultaneously improving the rate of indicated examinations (ambulatory environment

Added benefit was that while RBM pre-certification required an average of 10 minutes of interaction, the CDSS only required 10 seconds Efficient workflow and scheduling, with a

diminished need to reschedule patients

Decision Support

Clinician Radiologist

ACR – National Decision Support Clearinghouse

EMRCPOE

Radiology CDS

Radiology RIS

High Appropriateness

score

EMRCPOE

Radiology CDS

Radiology RIS

High Appropriateness

score

Low Appropriateness Score- Try

Again!

Radiology Order Entry Clinical Decision Support

Imaging 3.0: A Framework for Radiologists’ Future

Utilization Management 3.0

• Drive towards appropriate utilization of imaging– Ensure value of proper

imaging (and the Radiologists role) is defined as valuable

– Right test, right time, properly performed and interpreted

– Create a platform and tools to promote the value of imaging

Utilization Management and Value based Radiology

Bob Cooke

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Decision Support System

• The ACR Appropriateness Criteria ® must become a “digitally consumable” DSS to be used as part of a Clinical Decision Support System

• The ACR has formed a commercial entity so that the AC® can be used to integrate this “knowledge base” into CDS systems

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National Decision Support Company

• The ACR manages the content of the knowledge base. NDSC is the exclusive agent of the ACR for delivery of the content into the market

• NDSC is the commercial entity to manage the delivery and integration of this knowledge base into CDS systems

ACR’s Role

• Curates the clinical content based on market feedback obtained by NDSC, development of new imaging procedures, and member feedback.

Aggregate user experience

Content Updates Market Feedback

New Releases

CDS- Challenges

Issue Definition Approach to Resolution

Alert Fatigue users begins to ignore (white noise) or override alerts due to a high frequency of alerts

Content domains and triggers for the selected Imaging CDSS

Overriding CDSS interventions that appear all too frequently,

  Assess local practice and correct if necessary; re-assess AC

Delivery to the wrong population

Delivery of CDS to the correct user population also impacts adherence and success

Selectively turn off CDSS for certain category of clinicians.

Appropriateness Criteria is incorrect

Accuracy of CDSS is a critical factor in CDSS success

Review and correct in system. Feedback to clinical staff

Game the system Enter inaccurate information merely to obtain approval for desired examination

Look for disproportionate utilization even if seemingly justified. Check if rules never trigger. Counsel offenders (?Penalize- last resort)

Close the loop

Measure each clinicians performance Communication Compare anonymously to peers

Mount Sinai Experience

Data Collection Phase System is in place with discrete orders No feedback Determine Baseline performance

Presentation state is important Change management Utility scores of 1-3

Consistently 8% Educate

Plan – turn on feedback