IHE / RSNA Image Sharing Project - IHE Colombia Workshop (12/2014) Module 5c
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The document discusses the use of clinical decision support (CDS) systems to improve the appropriateness of radiology orders and utilization of imaging exams. It describes how CDS can integrate patient data, rules engines, and medical knowledge to produce patient-specific recommendations at the point of order entry based on standards like the ACR Appropriateness Criteria. The document outlines some of the challenges of CDS implementation as well as strategies used in a pilot at the Mount Sinai Medical Center to provide clinicians with feedback to improve their imaging ordering patterns over time.
IHE / RSNA Image Sharing Project - IHE Colombia Workshop (12/2014) Module 5c
- 1. 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 IHEWorkshop by: Elliot B. Sloane, PhD, CCE, FHIMSS Co-chair IHE International Board President, Center for Healthcare Information Research and Policy (CHIRP)
- 2. 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 ModalityWorklist Standard Protocols mapped to a modality RADLEX Playbook Series pre-defined What do we need? Enablers
- 3. Radiology Orders Appropriateness Cost Control
- 4. 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
- 5. 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
- 7. Iglehart JK. Health Insurers and Medical-Imaging Policy — A Work in Progress. N Engl J Med 2009;360:1030-1037
- 8. A Roadmap for National Action on Clinical Decision Support-June 13, 2006
- 9. Decision Support Collegial advice Text references Web sites Computer systems Passive Active Alerts Reminders CorollaryOrders Guidelines
- 10. Clinical Decision Support Systems (CDSS or CDS) Incorporates Patient data (EHR) Rules Engine Medical Knowledge Produces a patient specific recommendation
- 11. 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.
- 12. 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
- 13. 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?
- 14. 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
- 16. Decision Support Clinician Radiologist ACR – National Decision Support Clearinghouse
- 18. EMR CPOE Radiology CDS Radiology RIS HighAppropriateness score Low Appropriateness Score-Try Again!
- 19. Radiology Order Entry Clinical Decision Support
- 20. Imaging 3.0: A Framework for Radiologists’ Future
- 21. 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
- 22. Utilization Management and Value based Radiology Bob Cooke
- 23. 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 23
- 24. 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 24
- 25. 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
- 26. 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)
- 27. Close the loop Measure each clinicians performance Communication Compare anonymously to peers
- 28. 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
Editor's Notes
- #21: We are here today to talk about a concept called Imaging 3.0 that has been put forth by the American College of Radiology. Imaging 3.0 is more than an initiative of the ACR. It is a critical framework for the future of radiology—one that involves all radiologists, support professionals, IT teams, and vendors. Simply put, Imaging 3.0 brings together the information and tools to create a framework that will help the radiology community navigate the transition from volume-based care to value-based care.
- #22: maging 3.0 is a change process led by the ACR for the field of radiology. It includes a set of technology tools that equip 21st-century radiologists to ensure their key role in evolving health care delivery and payment models—and quality patient care. Define Utilization Management How current models have used payment reduction as UM management tool Opportunity to drive quality with a better approach to UM driven by ACRSelect Introduce linkage to Imaging 3.0 NEED BETTER TEXT. LINK IMAGING 3.0 Concept of new value, one of them is Radiologist as UM.
- #24: Decision Support System Define process to create computer based model from the AC
- #25: Introduce ACRSelect Define NDSC role
- #26: Define ACR Role Content Curation. Describe feedback model. ACR is “source of truth. Not a static knowledge base