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Clinical Decision Support: The first step to quality in imaging

by Sruti Nataraja and Ty Aderhold

In imaging, quality truly begins at the ordering stage. Ensuring that only the most appropriate imaging exams take place is the first step to high quality imaging. 

Inappropriate imaging wastes the time of patients and the health system. Additional imaging also comes with additional patient safety risks such as radiation dose, and when the imaging is unnecessary these risks are no longer balanced by the upside that normal imaging brings. Furthermore, inappropriate imaging can delay a proper diagnosis, as care providers spend time waiting on and then reviewing an exam that will not provide answers.

Even the clearest image, captured with the safest protocols, is low-quality if it was not needed in the first place.

The importance of appropriateness is summarized in a conceptual equation that a leading thinker in radiology at a large academic medical center introduced to our team during our research:

In this equation, all other aspects of quality imaging are multiplied by appropriateness. If an exam is inappropriate, appropriateness becomes zero, making quality zero overall.

A key role for imaging to play

It may seem that ensuring appropriateness is the responsibility of referring physicians. However, it has become increasingly clear that this expectation is unrealistic. Clinical guidelines are constantly being developed and refined, which means that staying up-to-date can be challenging—especially for referring providers who see many different types of patients with a variety of symptoms. Radiologists and imaging leaders, as the clinical experts, should take the lead on ensuring appropriateness.

Medicare, too, shares this view of radiology’s responsibility. As of January 1, 2018, the federal government requires referring providers to consult a clinical decision support (CDS) tool for all advanced outpatient imaging exams—a policy designed to elevate imaging appropriateness. But it is imaging providers, not referrers, who risk losing Medicare reimbursement if this consultation does not take place.

Tackling the appropriateness challenge with CDS

While the looming deadline may be the major catalyst for CDS implementation, imaging programs should recognize the opportunity that the tool provides to reduce inappropriate imaging and therefore improve quality. Through our research we have found that successful CDS implementation leads to a significant reduction in inappropriate exams.

For example, Virginia Mason began their CDS implementation with a small-scale rollout with three of the most overused imaging exams: lumbar spine MRI for low back pain, brain MRI for headache, and sinus CT for sinusitis. Each of these low-utility, high-volume, and high-cost exams was classified as unnecessary by clear appropriate use guidelines. Virginia Mason rolled out CDS for these three exams and prevented providers from ordering against the clinical guidelines without consulting a member of a multidisciplinary team of experts. After implementing this system, they found a 24.4% average percentage decrease in utilization rate for the targeted procedures.

One issue that can reduce the effectiveness of CDS is the fact that many clinicians use a non-physician proxy to order imaging exams. This means that they do not see and learn from the CDS feedback. To help combat this issue, Massachusetts General Hospital implemented a "Hard-Stop on Red" (HSOR), which required a clinician to log in and sign for any "low-value" exam that scored 3 or below on a 1-9 appropriateness scale.

After implementing this system:

  • The percentage of total imaging exams that were requested by clinicians (rather than other staff) doubled;
  • The percentage of scheduled exams graded "low value" fell from 5.43% to 1.92%; and
  • Perhaps most importantly, the percentage of "low-value" initiated orders fell from 6.34% to 4.77%—suggesting that the program succeeded not only in stopping inappropriate scans from hitting the schedule, but also in educating referring physicians and influencing their ordering habits.

Successful CDS implementation has benefits beyond improving appropriateness

Although CDS is primarily focused on reducing inappropriate imaging, successful implementation may also provide tangible efficiency improvements. By supplying providers with a clinical guide at the ordering stage, CDS can limit the need for time-consuming clarification calls back to referring providers after an exam is ordered. Furthermore, by catching inappropriate exams at the point of order, CDS can help reduce changes to orders or cancelations after an unnecessary imaging exam is scheduled. Finally, it can improve access to necessary imaging by clearing schedules of inappropriate exams.

So how can imaging leaders effectively implement CDS and capture these benefits? To get the most out of CDS, imaging programs should carefully consider which CDS vendor will work best with their current IT infrastructure and how to utilize data that CDS captures. Most importantly, they should engage stakeholders from across the system, including ordering providers, throughout the selection and implementation process.

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