The Reading Room

Does CDS curb imaging orders? Aurora Health Care says yes.

by Catherine Kosse and Erin Lane

In just eight months, Medicare will require ordering providers to consult appropriate use criteria (AUC) via an electronic clinical decision support (CDS) tool when ordering outpatient advanced imaging exams. When executed properly, CDS can facilitate more appropriate use of imaging, hardwire care standards, and reduce total cost of care. But, with few recent studies assessing the tool's impact, many health care leaders are left wondering what to expect after implementation. A recent study from Aurora Health Care sheds light on potential outcomes.

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CDS reduces inappropriate imaging orders

From December 2016 to December 2017, Aurora Health Care studied the impact of CDS on imaging orders through a randomized trial of 3,511 providers, about half of whom received best practice CDS alerts and half of which did not.

All imaging orders targeted by CDS saw a 6% reduction, the majority of which were CT exams. Specifically, CT exams reduced 9% and MRI exams 2% when providers used CDS compared with those who did not. The results align with earlier studies indicating the CDS leads to a shift away from higher radiation modalities in an effort to reduce radiation exposure.

Beyond an increase in imaging appropriateness, Aurora providers showed no evidence of "alert fatigue" (i.e. ignoring alerts) during the study period. This is an important finding, as CDS tools are effective only when used correctly. Unfortunately, many organizations struggle with provider adherence to the tool, a step that is necessary for the tool to improve appropriateness and patient care.

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Encourage provider adherence to maximize CDS potential

After CDS implementation, more often than not, organizations experience some level of provider resistance to the tool. This reaction includes "gaming" the system by using free text rather than structured indications, or selecting the first indication in the list to speed up workflow. Alternatively, providers may input correct information but ignore alerts.

Despite these challenges, there are strategies organizations can implement to ensure correct use of the tool.

  1. Deliver timely, actionable feedback: Create reports that display provider-level data and integrate these reports into ongoing CDS education. This approach holds users accountable and shares knowledge about how to best use the tool. This strategy alone increased Brigham and Women's Hospital's CDS provider adherence rate to 96%.

  2. Selectively deploy hard stops: Hard stops are alerts that temporarily or permanently prevent exam orders. In the context of CDS, organizations can implement alerts that require providers to select a structured indication instead of relying on the "free text" field. This prevents "gaming" of the system, and creates more reliable data and patient records. However, leaders should closely weigh the pros and cons of implementing hard stops as to not overly frustrate CDS users.

Ultimately, it's important to design an adherence strategy that works for your provider base so the organization realizes the greatest CDS benefits. CDS consultation can result in many benefits, but if used incorrectly, it can result in provider frustration and noncompliance with the Medicare mandate.

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