Whitney Palmer

Healthcare. Politics. Family.

Clinical Decision Support in Radiology: Its Time Is Now

Published on the Dec. 27, 2012 Diagnostic Imaging website

By Whitney L.J. Howell

There’s been a great deal of discussion in recent years about using clinical decision support (CDS) systems to ensure that imaging studies ordered and performed are appropriate. But the use of such systems in radiology isn’t a new idea. For the past decade providers and policymakers have discussed the proper use and implementation of CDS programs.

In the December issue of the Journal of the American College of Radiology, Hanna Zafar, MD,

Hanna Zafar, MD, assistant professor radiology at the Hospital of the University of Pennsylvania

Hanna Zafar, MD, assistant professor radiology at the Hospital of the University of Pennsylvania

assistant professor radiology at the Hospital of the University of Pennsylvania, discussed the history, benefits, and challenges associated with CDS systems in radiology. Diagnostic Imaging spoke with her about this paper.

Why did you decide to take a look at all the legislation that includes or impacts clinical decision support?

We were trying to convey that the policies regarding clinical decision support addressed in the American Recovery and Reinvestment Act (ARRA) did not appear overnight but were built on a long legislative history. Since 2003 policymakers have been interested in the use of CDS both for health care in general, as well as public reporting and radiology through the use of financial incentives and penalties. ARRA builds on the foundation established by this prior legislation in order to try and improve the quality, deliver and reporting of imaging procedures.

What are the major benefits of using CDS? What is the impact?

It’s important to understand that the implementation of CDS in imaging is part of a continued pattern to improve the quality, delivery and reporting of imaging procedures. Imaging CDS was not created to penalize radiologists or target imaging negatively. It is also important to remember that CDS is only applicable to those situations where evidence based guidelines exist.

CDS provides several benefits to clinicians, radiologists and patients. The chief benefit to clinicians is that it educates providers on evidence-based guidelines relating to imaging at the time of image order entry. That last phrase is critical because although many excellent guidelines exist, it’s not feasible for clinicians to refer to those guidelines at the time of ordering an imaging examination. The fact that these guidelines can be distilled into key clinical questions allows the system to interact with and give feedback to the provider in a seamless manner. Imaging CDS can also reduce inappropriate or redundant studies by providing alternative imaging procedures that are better suited to answer a clinical question per evidence-based guidelines or by highlighting the results of prior, potentially relevant, imaging procedures to help reduce redundant testing.

CDS also provides several benefits to radiologists. On a concrete level, it requires the input of relevant and pertinent pieces of clinical history into the physician order entry at the time of the clinical study order. If available to radiologists at the time of study interpretation, this clinical information can be extremely helpful in how we evaluate and interpret reports.

Specifically, this clinical data can help us to better understand why a clinician is ordering a study and to ensure that our report answers the critical clinical question for the provider and the patient. Reduction of inappropriate and redundant testing is also beneficial to radiologists in that it allows us to focus on appropriate imaging procedures. Radiologists, similar to other specialties, want to improve patient care through the optimal use of diagnostic imaging and of health care resources.

Finally, from the patient perspective, imaging CDS can improve patient safety through avoidance of unnecessary radiation from inappropriate or redundant procedures and the effect of unnecessary downstream procedures, such as the management of incidental findings.

On a more global note, imaging CDS offers a very exciting and novel opportunity to tie utilization of evidence-based imaging guidelines with patient outcomes. Imaging-related outcomes have long been a grey zone for radiologists because we don’t order imaging procedures, and we often don’t have easy or reliable access to relevant clinical history. Access to outcomes data will be valuable for us as radiologists, and it will be increasingly important for future policy and legislative decisions.

Are there challenges to implementing a clinical decision support system on a large scale?

The success of imaging CDS in reducing inappropriate imaging procedures thus far has been demonstrated in single institutional or health system studies and within a handful of states. We are optimistic that these results can be replicated on a larger national scale. However, this remains to be seen. An important point to remember is that even though there are no guarantees that imaging CDS utilization will translate necessarily or easily into improved quality and outcomes, it will bring us closer to understanding the relationship between guidelines and patient outcomes. This knowledge will allow us to begin to improve imaging utilization.

As for challenges in imaging CDS implementation, there are several that we can anticipate and others that we will likely have to address as they come. One of the main anticipated challenges is that imaging CDS relies on the existence of high quality guidelines. To date, imaging CDS has focused on clinical areas involving such guidelines as the use of lumbar spine MRI for lower back pain or CT pulmonary angiography for suspected pulmonary embolism. However, there are many imaging procedures that involve clinical scenarios for which we don’t have high quality guidelines. This will be an obstacle.

Another challenge for imaging CDS is variability in practice patterns among geographic regions, specialties and even individual providers. For some clinicians, imaging CDS is perceived as “cookie-cutter medicine” or a waste of time. There will always be some degree of resistance to any change in medicine, but nothing powerful enough to deter the need to explore the potential of imaging CDS to improve the deliver of radiology procedures.

To read the remainder of the Q&A at its original location: http://www.diagnosticimaging.com/informatics-pacs/content/article/113619/2121063?pageNumber=1

January 2, 2013 Posted by | Healthcare | , , , , , , , , , , | Leave a comment

Considering Appropriateness, Dose to Improve Patient Experience

Published on the Nov. 17, 2011, DiagnosticImaging.com website

By Whitney L.J. Howell

At conferences or departmental meetings, you’ve likely noticed a recurring subject: improving patient experience. It’s a hot trend in radiology, and some in the industry believe making it a reality takes more than better imaging machines.

In the age of healthcare reform, boosting patient satisfaction with the services you provide is critical to reimbursement. Many of you have purchased open or wide-bore MRI machines with higher Tesla strength to make your claustrophobic patients more comfortable. Or maybe you’ve added a scanner just for children. But your imaging technology is only part of the fix, according to some in the industry.

Ultimately, you should question every study you’re asked to perform.

“We know in the United States that 25 to 30 percent of radiology studies are done inappropriately without a good clinical reason,” said Stephen Herman, MD, president of MedCurrent, a Los Angeles-based radiology decision support consulting firm. “Either patients are demanding studies or doctors are practicing defensive medicine. The fact is there’s overutilization, but there are ways to avoid that.”

Getting the Test Right

Many factors go into selecting the correct diagnostic test — concerns over dosage, desires for good image quality, and deliberations about the best modality. For primary care providers who aren’t privy to ongoing best-practice conversations, ordering the best test for their patient isn’t always easy.

This is where a clinical decision support system (CDS) can play a role.

If a referring physician orders the wrong diagnostic test based on a patient’s history and current condition, a CDS can compare the order to existing benchmark data and suggest a more appropriate study. Not only does it eliminate the need for a radiologist to conduct multiple studies, but it’s also courteous to the patient, said Herman, who’s company manufactures the OrderRight™ CDS system.

“If a physician orders the incorrect imaging scan, the patient has to take more time to come back in, pay another co-pay, and potentially deal with the inconvenience for rescheduling other activities,” he said. “Most importantly, however, having to return to have the right test done will result in an avoidable delay in patient care.”

To read the remainder of the story: http://www.diagnosticimaging.com/practice-management/content/article/113619/1993500

November 18, 2011 Posted by | Healthcare | , , , , , , , , , , , , , , , , , , , , , , , , , , , | Leave a comment

Taking Steps to Improve Radiation Safety

Published on DiagnosticImaging.com on March 14, 2011

By Whitney L.J. Howell

Radiology currently has two buzzwords: safety and low dose. And, it’s a trend that’s been growing for the past five years.

Throughout the industry, radiologists and referring physicians are using a number of strategies to limit patient exposure to unneeded radiation. New programs, equipment, and contrast agents are being used together to drastically reduce the amount of radiation patients receive.

Safety and low-dose vigilance really kicked into high gear when the Biological Effects of Ionizing Radiation VII report came out in 2005. Media reports over the perceived dangers of radiation exposure prompted calls for measures that would protect patients, with the two main worries being accidental over-irradiation due to CT scan protocol errors and potential cancer risks associated with radiation.

The pendulum is now swinging toward limiting doses whenever possible. Through its Image Wisely and Image Gently campaigns, the American College of Radiology (ACR) and its partners have provided guidance and encouragement for reducing the amount of radiation used with both adults and children, respectively.

“The specialty is taking steps to improve safety. When it comes to doses, it’s all about ALARA — as low as reasonably achievable,” said James Thrall, MD, ACR President and Massachusetts General Hospital radiologist-in-chief. “The good news is that there are a tremendous number of technical innovations and clinical practices that are rapidly reducing exposure from CT scanning.”

To read the remainder of the article: http://bit.ly/haWvdn



March 17, 2011 Posted by | Healthcare, Science | , , , , , , , , , , , , , , , , , , , , , , , , , , , | Leave a comment


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