Clinical Decision Support Systems - CADTH.ca...Clinical Decision Support in the pan Canadian Digital Health Landscape 33 • Established in 2001 as an independent, not-for-profit corporation

Clinical Decision

Support Systems Implications for Advancing Optimal

Medical Imaging Use in Canada

DISCLOSURE bull Relationship with Commercial Interest

bull GrantResearch Support

bull Speaker BureauHonoraria

bull Consulting fees

bull Memberships on advisory committees boards

bull Other Affiliations

Clinical Decision



A Perspective From A

Frontline CDS User Brian H Rowe MD MSc

Emergency Physician University of Alberta Hospital

Co-Chair Choosing Wisely Working Group

Canadian Association of Emergency Physicians (CAEP)

Professor Department of Emergency Medicine

University of Alberta

DISCLOSURE B Rowe bull Relationship with Commercial Interest None

bull Employment University of AlbertaCIHR

bull GrantResearch Support CIHR AHS AIHS

bull Speaker BureauHonoraria None

bull Consulting fees None

bull Memberships on advisory committees boards CIHR

bull Other Affiliations will be passing the hat at the end

of the session

Emergency Department

bull Clinicians working in

emergency departments face

pressure to reduce delays

bull Practice variation is well

documented

bull Most EDs are paper-based

(although this is changing)

bull CDS are well developed

5

CDS in Emergencies bull Pneumonia severity CURB-65 PSI

bull Pulmonary embolism PERC Wellrsquos

more

bull DVT Wellrsquos criteria

bull C-spine Canadian C-Spine rule

bull Concussion Canadian CT Head Rule

bull Anklefoot Ottawa Ankle Rule

bull Evidence no longer the issue

bull So many rules so little time

6

Emergency Department Reality bull ED overcrowding and long waits

are common in Canada

bull Crowding related to

bull Input factors

bull Throughput factors

bull Output factors and

bull System factors

bull One more reason for

unnecessary testing procedures

and treatment

7

Example CT Scans for mTBI

bull Reasonably easy to acquire at most large hospitals

bull Risks bull Radiation

exposure

bull Time in ED

bull Costs

bull Does everyone need one

Canadian CT Head Rules bull Well-validated sensitive

decision rule for use of CT head in mTBI

bull Canadian CT head rule (CCTHR) for minor head injuries

bull CCTHR performance bull Sn = 100 if you have no

criteria the risk of a serious head injury is ~0 (1 10000)

bull Decreases need for CT and time in ED

bull Still need to provide concussion FU

Stiell I et al JAMA 2005294(12)1511-1518

hellipbut its hard to change practice

bull 12 Canadian Centres bull Controls (n = 6) standard

practice bull Intervention sites (n = 6)

bull Strategies to implement CCT to reduce CT ordering

bull Paper-based to computer-based

bull Each strategy required ED MDs to complete a CCT sheet regarding CT ordering

Patterns Irsquove always done it this

way

Patterns Better to do

something than nothing

Demand The patient ldquowantsrdquo it

Innovation New tests are

good

Peer Pressure Referring doctor

wants it

Fear I donrsquot want to

get sued

Income Financial incentives

Physicians Common reasons for tests procedures and therapies

CAEP Approach

bull Initiated CWC WG and surveyed members

bull Developed CWCCAEP lists

bull Top-5 2015

bull Top-10 2017

bull Dissemination passive (websites + local)

bull Evaluation limited

bull Some regions evaluation grants (PRIHS)

bull Debate continues

12

Solutions bull Valid and reliable utilization

data

bull Evidence-based solutions

bull CDS incorporated into

electronic medical record

bull Computerized physician order

entry

bull Audit and feedback strategies

(but not too much)

13

National Approaches

14

Thank you QuestionsComments

15

Diagnostic Imaging

Referral Guidelines

Martin H Reed MD FRCPC FACR FCAR

Chair Referral Guidelines Working Group

Canadian Association of Radiologists

DISCLOSURE

bull Relationship with Commercial Interest no

bull GrantResearch Support no

bull Speaker BureauHonoraria no

bull Consulting fees CADTH

bull Memberships on advisory committees boards no

bull Other Affiliations Canadian Association of

Radiologists

Diagnostic Imaging Referral

Guidelines bull iRefer - The Royal College of Radiologists (1989)

bull Appropriateness Criteria ndash The American College of

Radiology (1993)

Guide du bon usage des examens drsquoimagarie

meacutedicale - La Socieacuteteacute Franccedilaise de Radiologie

bull Diagnostic Imaging Pathways

bull Diagnostic Imaging Referral Guidelines ndash Canadian

Association of Radiologists


Guidelines CAR Diagnostic Imaging Referral Guidelines


Guidelines ACR Appropriateness Criteria


Guidelines Diagnostic Imaging Pathways

Computerized Decision

Support bull Canadian Association of Radiologists

bull J Am Coll Radiol 20118251-8The effect of incorporating guidelines into a

computerized order entry system for diagnostic imaging Bowen S1 Johnson K

Reed MH et al

bull J Am Med Inform Assoc 201118267-70 Electronic decision support for diagnostic

imaging in a primary care setting Curry L1 Reed MH

bull American College of Radiology

bull ACR Select

bull European Society of Radiology

bull iGuide

bull The Royal College of Radiologists

Thank You

23

Clinical Decision

Support Systems

Mark MacMillan

Director Clinical Decision Support

Diagnostic Imaging AHS

DISCLOSURE

bull Relationship with Commercial Interest None

bull GrantResearch Support None



bull Memberships on advisory committees boards None

bull Other Affiliations Alberta Health Service Employee

Utilization vs Appropriateness

26

Albertarsquos Opportunity

bull AHS Diagnostic Imaging

bull Connect Care Initiative

bull Clinical Decision Support

Framework

bull 2019 Alberta CDS

Integration

27

bull the right information

bull to the right person

bull in the right intervention

format

bull through the right channel

bull at the right time in workflow

Clinician Engagement

28

bull De- implementation

bull Physician Learning

bull Audit and Feedback

bull Learn from the past

Thank You

29

References

CT Utilization by Population

CADTH Medical Imaging Inventory

5 rights of clinical decision support

ldquoImproving Outcomes with CDS An Implementerrsquos Guide (second edition)rdquo written by by Jerome

Osheroff MD in 2012

CDS Cube

ldquoCIS FrameworksndashClinical Decision Supportrdquo Alberta Health Services concept Dr Allen Ausford

Dr Rob Hayward Dr Doug Campbell

Clinical Decision

Support Systems Lynne Zucker

Executive Vice President ACCESS

Health

Canada Health Infoway







Canada Health Infoway Clinical Decision Support in the pan Canadian Digital Health Landscape

33

bull Established in 2001 as an independent not-for-profit corporation

bull Equally accountable to 14 federal provincial and territorial governments through the Members (fpt

Deputy Ministers of Health) who appoint the independent Board of Directors

bull Since inception $245 billion in capitalization from the federal government through Health Canada

Electronic health records (EHRs)

2001 $500M

EHRs Standards amp Telehealth

2003 $600M

Public Health Surveillance Systems

2004 $100M

EHRs amp Wait Time Systems

2007 $400M

Electronic Medical Records (EMRs)

2010 $500M

2017-2022 $300M

Foundational Mandate - Completed Current Mandate

E-Prescribing amp Telehomecare

2016-2018 $50M

E-Prescribing Virtual Care Patient Access to Health Information Linking EHR Systems

2017-2022 $300M

Evolution of Infowayrsquos Activities

34

2017-2022 $300M

Opportunity for Clinical Decision Support

bull Standardized guidelines available at time of referral or

ordering have made little progress integrating with

primary care EMRs - while it is acknowledged as a best

practice

bull A pan-Canadian CDS framework and business case for

integration into community based clinical systems is

required This will require co-ordination between the

various ldquoguideline ownersrdquo and possibly shared

infrastructure

35

ldquoUsed appropriately and based on quality EMR data

CDS tools have a great potential to improve the

efficiency and

quality of care provided within a family practicerdquo

Thank You

36

Clinical Decision

Support Systems What is the evidence

Harindra Wijeysundera

Vice President Medical Devices amp Clinical

Interventions

CADTH

DISCLOSURE bull Relationship with Commercial Interest none

bull GrantResearch Support Edwards Lifesciences and

Medtronic Inc

bull Speaker BureauHonoraria none

bull Consulting fees none


CorHealth Cardiac Funding Reform

bull Other Affiliations CADTH exec

What is the evidence

Rapid Response Report

Clinical Decision Support Systems for Appropriate Medical

Imaging Clinical Evidence and Cost-Effectiveness

January 2019

Findings

bull Mixed results

bull One systematic review

bull Prospective (3) and retrospective before and after studies

(11)

bull 2 RCT

bull Signal of increase yield and clinical benefit with no

evidence of harm

40

Findings

Why is this so difficult to study

bull Wrong intervention

bull Wrong design

bull Temporal impact

bull What is the right outcome

bull Bias to the null

41

42







Clinical Decision

















of the session






documented




5



more







6




bull Input factors



bull System factors



and treatment

7




exposure

bull Time in ED

bull Costs

















way





good


wants it


get sued



CAEP Approach



bull Top-5 2015

bull Top-10 2017





12


data





entry


(but not too much)

13

National Approaches

14


15

Diagnostic Imaging

Referral Guidelines




DISCLOSURE







Radiologists




Radiology (1993)
















Reed MH et al




bull ACR Select


bull iGuide


Thank You

23

Clinical Decision

Support Systems

Mark MacMillan



DISCLOSURE








26





Framework


Integration

27




format




28





Thank You

29

References





Osheroff MD in 2012

CDS Cube



Clinical Decision



Health









33






2001 $500M


2003 $600M


2004 $100M


2007 $400M


2010 $500M

2017-2022 $300M



2016-2018 $50M


2017-2022 $300M


34

2017-2022 $300M





practice





infrastructure

35



efficiency and


Thank You

36

Clinical Decision




Interventions

CADTH



Medtronic Inc










January 2019

Findings

bull Mixed results



(11)

bull 2 RCT


evidence of harm

40

Findings



bull Wrong design




41

42

Clinical Decision

















of the session






documented




5



more







6




bull Input factors



bull System factors



and treatment

7




exposure

bull Time in ED

bull Costs

















way





good


wants it


get sued



CAEP Approach



bull Top-5 2015

bull Top-10 2017





12


data





entry


(but not too much)

13

National Approaches

14


15

Diagnostic Imaging

Referral Guidelines




DISCLOSURE







Radiologists




Radiology (1993)
















Reed MH et al




bull ACR Select


bull iGuide


Thank You

23

Clinical Decision

Support Systems

Mark MacMillan



DISCLOSURE








26





Framework


Integration

27




format




28





Thank You

29

References





Osheroff MD in 2012

CDS Cube



Clinical Decision



Health









33






2001 $500M


2003 $600M


2004 $100M


2007 $400M


2010 $500M

2017-2022 $300M



2016-2018 $50M


2017-2022 $300M


34

2017-2022 $300M





practice





infrastructure

35



efficiency and


Thank You

36

Clinical Decision




Interventions

CADTH



Medtronic Inc










January 2019

Findings

bull Mixed results



(11)

bull 2 RCT


evidence of harm

40

Findings



bull Wrong design




41

42















of the session






documented




5



more







6




bull Input factors



bull System factors



and treatment

7




exposure

bull Time in ED

bull Costs

















way





good


wants it


get sued



CAEP Approach



bull Top-5 2015

bull Top-10 2017





12


data





entry


(but not too much)

13

National Approaches

14


15

Diagnostic Imaging

Referral Guidelines




DISCLOSURE







Radiologists




Radiology (1993)
















Reed MH et al




bull ACR Select


bull iGuide


Thank You

23

Clinical Decision

Support Systems

Mark MacMillan



DISCLOSURE








26





Framework


Integration

27




format




28





Thank You

29

References





Osheroff MD in 2012

CDS Cube



Clinical Decision



Health









33






2001 $500M


2003 $600M


2004 $100M


2007 $400M


2010 $500M

2017-2022 $300M



2016-2018 $50M


2017-2022 $300M


34

2017-2022 $300M





practice





infrastructure

35



efficiency and


Thank You

36

Clinical Decision




Interventions

CADTH



Medtronic Inc










January 2019

Findings

bull Mixed results



(11)

bull 2 RCT


evidence of harm

40

Findings



bull Wrong design




41

42








of the session






documented




5



more







6




bull Input factors



bull System factors



and treatment

7




exposure

bull Time in ED

bull Costs

















way





good


wants it


get sued



CAEP Approach



bull Top-5 2015

bull Top-10 2017





12


data





entry


(but not too much)

13

National Approaches

14


15

Diagnostic Imaging

Referral Guidelines




DISCLOSURE







Radiologists




Radiology (1993)
















Reed MH et al




bull ACR Select


bull iGuide


Thank You

23

Clinical Decision

Support Systems

Mark MacMillan



DISCLOSURE








26





Framework


Integration

27




format




28





Thank You

29

References





Osheroff MD in 2012

CDS Cube



Clinical Decision



Health









33






2001 $500M


2003 $600M


2004 $100M


2007 $400M


2010 $500M

2017-2022 $300M



2016-2018 $50M


2017-2022 $300M


34

2017-2022 $300M





practice





infrastructure

35



efficiency and


Thank You

36

Clinical Decision




Interventions

CADTH



Medtronic Inc










January 2019

Findings

bull Mixed results



(11)

bull 2 RCT


evidence of harm

40

Findings



bull Wrong design




41

42






documented




5



more







6




bull Input factors



bull System factors



and treatment

7




exposure

bull Time in ED

bull Costs

















way





good


wants it


get sued



CAEP Approach



bull Top-5 2015

bull Top-10 2017





12


data





entry


(but not too much)

13

National Approaches

14


15

Diagnostic Imaging

Referral Guidelines




DISCLOSURE







Radiologists




Radiology (1993)
















Reed MH et al




bull ACR Select


bull iGuide


Thank You

23

Clinical Decision

Support Systems

Mark MacMillan



DISCLOSURE








26





Framework


Integration

27




format




28





Thank You

29

References





Osheroff MD in 2012

CDS Cube



Clinical Decision



Health









33






2001 $500M


2003 $600M


2004 $100M


2007 $400M


2010 $500M

2017-2022 $300M



2016-2018 $50M


2017-2022 $300M


34

2017-2022 $300M





practice





infrastructure

35



efficiency and


Thank You

36

Clinical Decision




Interventions

CADTH



Medtronic Inc










January 2019

Findings

bull Mixed results



(11)

bull 2 RCT


evidence of harm

40

Findings



bull Wrong design




41

42



more







6




bull Input factors



bull System factors



and treatment

7




exposure

bull Time in ED

bull Costs

















way





good


wants it


get sued



CAEP Approach



bull Top-5 2015

bull Top-10 2017





12


data





entry


(but not too much)

13

National Approaches

14


15

Diagnostic Imaging

Referral Guidelines




DISCLOSURE







Radiologists




Radiology (1993)
















Reed MH et al




bull ACR Select


bull iGuide


Thank You

23

Clinical Decision

Support Systems

Mark MacMillan



DISCLOSURE








26





Framework


Integration

27




format




28





Thank You

29

References





Osheroff MD in 2012

CDS Cube



Clinical Decision



Health









33






2001 $500M


2003 $600M


2004 $100M


2007 $400M


2010 $500M

2017-2022 $300M



2016-2018 $50M


2017-2022 $300M


34

2017-2022 $300M





practice





infrastructure

35



efficiency and


Thank You

36

Clinical Decision




Interventions

CADTH



Medtronic Inc










January 2019

Findings

bull Mixed results



(11)

bull 2 RCT


evidence of harm

40

Findings



bull Wrong design




41

42




bull Input factors



bull System factors



and treatment

7




exposure

bull Time in ED

bull Costs

















way





good


wants it


get sued



CAEP Approach



bull Top-5 2015

bull Top-10 2017





12


data





entry


(but not too much)

13

National Approaches

14


15

Diagnostic Imaging

Referral Guidelines




DISCLOSURE







Radiologists




Radiology (1993)
















Reed MH et al




bull ACR Select


bull iGuide


Thank You

23

Clinical Decision

Support Systems

Mark MacMillan



DISCLOSURE








26





Framework


Integration

27




format




28





Thank You

29

References





Osheroff MD in 2012

CDS Cube



Clinical Decision



Health









33






2001 $500M


2003 $600M


2004 $100M


2007 $400M


2010 $500M

2017-2022 $300M



2016-2018 $50M


2017-2022 $300M


34

2017-2022 $300M





practice





infrastructure

35



efficiency and


Thank You

36

Clinical Decision




Interventions

CADTH



Medtronic Inc










January 2019

Findings

bull Mixed results



(11)

bull 2 RCT


evidence of harm

40

Findings



bull Wrong design




41

42




exposure

bull Time in ED

bull Costs

















way





good


wants it


get sued



CAEP Approach



bull Top-5 2015

bull Top-10 2017





12


data





entry


(but not too much)

13

National Approaches

14


15

Diagnostic Imaging

Referral Guidelines




DISCLOSURE







Radiologists




Radiology (1993)
















Reed MH et al




bull ACR Select


bull iGuide


Thank You

23

Clinical Decision

Support Systems

Mark MacMillan



DISCLOSURE








26





Framework


Integration

27




format




28





Thank You

29

References





Osheroff MD in 2012

CDS Cube



Clinical Decision



Health









33






2001 $500M


2003 $600M


2004 $100M


2007 $400M


2010 $500M

2017-2022 $300M



2016-2018 $50M


2017-2022 $300M


34

2017-2022 $300M





practice





infrastructure

35



efficiency and


Thank You

36

Clinical Decision




Interventions

CADTH



Medtronic Inc










January 2019

Findings

bull Mixed results



(11)

bull 2 RCT


evidence of harm

40

Findings



bull Wrong design




41

42
















way





good


wants it


get sued



CAEP Approach



bull Top-5 2015

bull Top-10 2017





12


data





entry


(but not too much)

13

National Approaches

14


15

Diagnostic Imaging

Referral Guidelines




DISCLOSURE







Radiologists




Radiology (1993)
















Reed MH et al




bull ACR Select


bull iGuide


Thank You

23

Clinical Decision

Support Systems

Mark MacMillan



DISCLOSURE








26





Framework


Integration

27




format




28





Thank You

29

References





Osheroff MD in 2012

CDS Cube



Clinical Decision



Health









33






2001 $500M


2003 $600M


2004 $100M


2007 $400M


2010 $500M

2017-2022 $300M



2016-2018 $50M


2017-2022 $300M


34

2017-2022 $300M





practice





infrastructure

35



efficiency and


Thank You

36

Clinical Decision




Interventions

CADTH



Medtronic Inc










January 2019

Findings

bull Mixed results



(11)

bull 2 RCT


evidence of harm

40

Findings



bull Wrong design




41

42








way





good


wants it


get sued



CAEP Approach



bull Top-5 2015

bull Top-10 2017





12


data





entry


(but not too much)

13

National Approaches

14


15

Diagnostic Imaging

Referral Guidelines




DISCLOSURE







Radiologists




Radiology (1993)
















Reed MH et al




bull ACR Select


bull iGuide


Thank You

23

Clinical Decision

Support Systems

Mark MacMillan



DISCLOSURE








26





Framework


Integration

27




format




28





Thank You

29

References





Osheroff MD in 2012

CDS Cube



Clinical Decision



Health









33






2001 $500M


2003 $600M


2004 $100M


2007 $400M


2010 $500M

2017-2022 $300M



2016-2018 $50M


2017-2022 $300M


34

2017-2022 $300M





practice





infrastructure

35



efficiency and


Thank You

36

Clinical Decision




Interventions

CADTH



Medtronic Inc










January 2019

Findings

bull Mixed results



(11)

bull 2 RCT


evidence of harm

40

Findings



bull Wrong design




41

42


way





good


wants it


get sued



CAEP Approach



bull Top-5 2015

bull Top-10 2017





12


data





entry


(but not too much)

13

National Approaches

14


15

Diagnostic Imaging

Referral Guidelines




DISCLOSURE







Radiologists




Radiology (1993)
















Reed MH et al




bull ACR Select


bull iGuide


Thank You

23

Clinical Decision

Support Systems

Mark MacMillan



DISCLOSURE








26





Framework


Integration

27




format




28





Thank You

29

References





Osheroff MD in 2012

CDS Cube



Clinical Decision



Health









33






2001 $500M


2003 $600M


2004 $100M


2007 $400M


2010 $500M

2017-2022 $300M



2016-2018 $50M


2017-2022 $300M


34

2017-2022 $300M





practice





infrastructure

35



efficiency and


Thank You

36

Clinical Decision




Interventions

CADTH



Medtronic Inc










January 2019

Findings

bull Mixed results



(11)

bull 2 RCT


evidence of harm

40

Findings



bull Wrong design




41

42

CAEP Approach



bull Top-5 2015

bull Top-10 2017





12


data





entry


(but not too much)

13

National Approaches

14


15

Diagnostic Imaging

Referral Guidelines




DISCLOSURE







Radiologists




Radiology (1993)
















Reed MH et al




bull ACR Select


bull iGuide


Thank You

23

Clinical Decision

Support Systems

Mark MacMillan



DISCLOSURE








26





Framework


Integration

27




format




28





Thank You

29

References





Osheroff MD in 2012

CDS Cube



Clinical Decision



Health









33






2001 $500M


2003 $600M


2004 $100M


2007 $400M


2010 $500M

2017-2022 $300M



2016-2018 $50M


2017-2022 $300M


34

2017-2022 $300M





practice





infrastructure

35



efficiency and


Thank You

36

Clinical Decision




Interventions

CADTH



Medtronic Inc










January 2019

Findings

bull Mixed results



(11)

bull 2 RCT


evidence of harm

40

Findings



bull Wrong design




41

42


data





entry


(but not too much)

13

National Approaches

14


15

Diagnostic Imaging

Referral Guidelines




DISCLOSURE







Radiologists




Radiology (1993)
















Reed MH et al




bull ACR Select


bull iGuide


Thank You

23

Clinical Decision

Support Systems

Mark MacMillan



DISCLOSURE








26





Framework


Integration

27




format




28





Thank You

29

References





Osheroff MD in 2012

CDS Cube



Clinical Decision



Health









33






2001 $500M


2003 $600M


2004 $100M


2007 $400M


2010 $500M

2017-2022 $300M



2016-2018 $50M


2017-2022 $300M


34

2017-2022 $300M





practice





infrastructure

35



efficiency and


Thank You

36

Clinical Decision




Interventions

CADTH



Medtronic Inc










January 2019

Findings

bull Mixed results



(11)

bull 2 RCT


evidence of harm

40

Findings



bull Wrong design




41

42

National Approaches

14


15

Diagnostic Imaging

Referral Guidelines




DISCLOSURE







Radiologists




Radiology (1993)
















Reed MH et al




bull ACR Select


bull iGuide


Thank You

23

Clinical Decision

Support Systems

Mark MacMillan



DISCLOSURE








26





Framework


Integration

27




format




28





Thank You

29

References





Osheroff MD in 2012

CDS Cube



Clinical Decision



Health









33






2001 $500M


2003 $600M


2004 $100M


2007 $400M


2010 $500M

2017-2022 $300M



2016-2018 $50M


2017-2022 $300M


34

2017-2022 $300M





practice





infrastructure

35



efficiency and


Thank You

36

Clinical Decision




Interventions

CADTH



Medtronic Inc










January 2019

Findings

bull Mixed results



(11)

bull 2 RCT


evidence of harm

40

Findings



bull Wrong design




41

42


15

Diagnostic Imaging

Referral Guidelines




DISCLOSURE







Radiologists




Radiology (1993)
















Reed MH et al




bull ACR Select


bull iGuide


Thank You

23

Clinical Decision

Support Systems

Mark MacMillan



DISCLOSURE








26





Framework


Integration

27




format




28





Thank You

29

References





Osheroff MD in 2012

CDS Cube



Clinical Decision



Health









33






2001 $500M


2003 $600M


2004 $100M


2007 $400M


2010 $500M

2017-2022 $300M



2016-2018 $50M


2017-2022 $300M


34

2017-2022 $300M





practice





infrastructure

35



efficiency and


Thank You

36

Clinical Decision




Interventions

CADTH



Medtronic Inc










January 2019

Findings

bull Mixed results



(11)

bull 2 RCT


evidence of harm

40

Findings



bull Wrong design




41

42

Diagnostic Imaging

Referral Guidelines




DISCLOSURE







Radiologists




Radiology (1993)
















Reed MH et al




bull ACR Select


bull iGuide


Thank You

23

Clinical Decision

Support Systems

Mark MacMillan



DISCLOSURE








26





Framework


Integration

27




format




28





Thank You

29

References





Osheroff MD in 2012

CDS Cube



Clinical Decision



Health









33






2001 $500M


2003 $600M


2004 $100M


2007 $400M


2010 $500M

2017-2022 $300M



2016-2018 $50M


2017-2022 $300M


34

2017-2022 $300M





practice





infrastructure

35



efficiency and


Thank You

36

Clinical Decision




Interventions

CADTH



Medtronic Inc










January 2019

Findings

bull Mixed results



(11)

bull 2 RCT


evidence of harm

40

Findings



bull Wrong design




41

42

DISCLOSURE







Radiologists




Radiology (1993)
















Reed MH et al




bull ACR Select


bull iGuide


Thank You

23

Clinical Decision

Support Systems

Mark MacMillan



DISCLOSURE








26





Framework


Integration

27




format




28





Thank You

29

References





Osheroff MD in 2012

CDS Cube



Clinical Decision



Health









33






2001 $500M


2003 $600M


2004 $100M


2007 $400M


2010 $500M

2017-2022 $300M



2016-2018 $50M


2017-2022 $300M


34

2017-2022 $300M





practice





infrastructure

35



efficiency and


Thank You

36

Clinical Decision




Interventions

CADTH



Medtronic Inc










January 2019

Findings

bull Mixed results



(11)

bull 2 RCT


evidence of harm

40

Findings



bull Wrong design




41

42




Radiology (1993)
















Reed MH et al




bull ACR Select


bull iGuide


Thank You

23

Clinical Decision

Support Systems

Mark MacMillan



DISCLOSURE








26





Framework


Integration

27




format




28





Thank You

29

References





Osheroff MD in 2012

CDS Cube



Clinical Decision



Health









33






2001 $500M


2003 $600M


2004 $100M


2007 $400M


2010 $500M

2017-2022 $300M



2016-2018 $50M


2017-2022 $300M


34

2017-2022 $300M





practice





infrastructure

35



efficiency and


Thank You

36

Clinical Decision




Interventions

CADTH



Medtronic Inc










January 2019

Findings

bull Mixed results



(11)

bull 2 RCT


evidence of harm

40

Findings



bull Wrong design




41

42











Reed MH et al




bull ACR Select


bull iGuide


Thank You

23

Clinical Decision

Support Systems

Mark MacMillan



DISCLOSURE








26





Framework


Integration

27




format




28





Thank You

29

References





Osheroff MD in 2012

CDS Cube



Clinical Decision



Health









33






2001 $500M


2003 $600M


2004 $100M


2007 $400M


2010 $500M

2017-2022 $300M



2016-2018 $50M


2017-2022 $300M


34

2017-2022 $300M





practice





infrastructure

35



efficiency and


Thank You

36

Clinical Decision




Interventions

CADTH



Medtronic Inc










January 2019

Findings

bull Mixed results



(11)

bull 2 RCT


evidence of harm

40

Findings



bull Wrong design




41

42









Reed MH et al




bull ACR Select


bull iGuide


Thank You

23

Clinical Decision

Support Systems

Mark MacMillan



DISCLOSURE








26





Framework


Integration

27




format




28





Thank You

29

References





Osheroff MD in 2012

CDS Cube



Clinical Decision



Health









33






2001 $500M


2003 $600M


2004 $100M


2007 $400M


2010 $500M

2017-2022 $300M



2016-2018 $50M


2017-2022 $300M


34

2017-2022 $300M





practice





infrastructure

35



efficiency and


Thank You

36

Clinical Decision




Interventions

CADTH



Medtronic Inc










January 2019

Findings

bull Mixed results



(11)

bull 2 RCT


evidence of harm

40

Findings



bull Wrong design




41

42







Reed MH et al




bull ACR Select


bull iGuide


Thank You

23

Clinical Decision

Support Systems

Mark MacMillan



DISCLOSURE








26





Framework


Integration

27




format




28





Thank You

29

References





Osheroff MD in 2012

CDS Cube



Clinical Decision



Health









33






2001 $500M


2003 $600M


2004 $100M


2007 $400M


2010 $500M

2017-2022 $300M



2016-2018 $50M


2017-2022 $300M


34

2017-2022 $300M





practice





infrastructure

35



efficiency and


Thank You

36

Clinical Decision




Interventions

CADTH



Medtronic Inc










January 2019

Findings

bull Mixed results



(11)

bull 2 RCT


evidence of harm

40

Findings



bull Wrong design




41

42





Reed MH et al




bull ACR Select


bull iGuide


Thank You

23

Clinical Decision

Support Systems

Mark MacMillan



DISCLOSURE








26





Framework


Integration

27




format




28





Thank You

29

References





Osheroff MD in 2012

CDS Cube



Clinical Decision



Health









33






2001 $500M


2003 $600M


2004 $100M


2007 $400M


2010 $500M

2017-2022 $300M



2016-2018 $50M


2017-2022 $300M


34

2017-2022 $300M





practice





infrastructure

35



efficiency and


Thank You

36

Clinical Decision




Interventions

CADTH



Medtronic Inc










January 2019

Findings

bull Mixed results



(11)

bull 2 RCT


evidence of harm

40

Findings



bull Wrong design




41

42

Thank You

23

Clinical Decision

Support Systems

Mark MacMillan



DISCLOSURE








26





Framework


Integration

27




format




28





Thank You

29

References





Osheroff MD in 2012

CDS Cube



Clinical Decision



Health









33






2001 $500M


2003 $600M


2004 $100M


2007 $400M


2010 $500M

2017-2022 $300M



2016-2018 $50M


2017-2022 $300M


34

2017-2022 $300M





practice





infrastructure

35



efficiency and


Thank You

36

Clinical Decision




Interventions

CADTH



Medtronic Inc










January 2019

Findings

bull Mixed results



(11)

bull 2 RCT


evidence of harm

40

Findings



bull Wrong design




41

42

Clinical Decision

Support Systems

Mark MacMillan



DISCLOSURE








26





Framework


Integration

27




format




28





Thank You

29

References





Osheroff MD in 2012

CDS Cube



Clinical Decision



Health









33






2001 $500M


2003 $600M


2004 $100M


2007 $400M


2010 $500M

2017-2022 $300M



2016-2018 $50M


2017-2022 $300M


34

2017-2022 $300M





practice





infrastructure

35



efficiency and


Thank You

36

Clinical Decision




Interventions

CADTH



Medtronic Inc










January 2019

Findings

bull Mixed results



(11)

bull 2 RCT


evidence of harm

40

Findings



bull Wrong design




41

42

DISCLOSURE








26





Framework


Integration

27




format




28





Thank You

29

References





Osheroff MD in 2012

CDS Cube



Clinical Decision



Health









33






2001 $500M


2003 $600M


2004 $100M


2007 $400M


2010 $500M

2017-2022 $300M



2016-2018 $50M


2017-2022 $300M


34

2017-2022 $300M





practice





infrastructure

35



efficiency and


Thank You

36

Clinical Decision




Interventions

CADTH



Medtronic Inc










January 2019

Findings

bull Mixed results



(11)

bull 2 RCT


evidence of harm

40

Findings



bull Wrong design




41

42


26





Framework


Integration

27




format




28





Thank You

29

References





Osheroff MD in 2012

CDS Cube



Clinical Decision



Health









33






2001 $500M


2003 $600M


2004 $100M


2007 $400M


2010 $500M

2017-2022 $300M



2016-2018 $50M


2017-2022 $300M


34

2017-2022 $300M





practice





infrastructure

35



efficiency and


Thank You

36

Clinical Decision




Interventions

CADTH



Medtronic Inc










January 2019

Findings

bull Mixed results



(11)

bull 2 RCT


evidence of harm

40

Findings



bull Wrong design




41

42





Framework


Integration

27




format




28





Thank You

29

References





Osheroff MD in 2012

CDS Cube



Clinical Decision



Health









33






2001 $500M


2003 $600M


2004 $100M


2007 $400M


2010 $500M

2017-2022 $300M



2016-2018 $50M


2017-2022 $300M


34

2017-2022 $300M





practice





infrastructure

35



efficiency and


Thank You

36

Clinical Decision




Interventions

CADTH



Medtronic Inc










January 2019

Findings

bull Mixed results



(11)

bull 2 RCT


evidence of harm

40

Findings



bull Wrong design




41

42


28





Thank You

29

References





Osheroff MD in 2012

CDS Cube



Clinical Decision



Health









33






2001 $500M


2003 $600M


2004 $100M


2007 $400M


2010 $500M

2017-2022 $300M



2016-2018 $50M


2017-2022 $300M


34

2017-2022 $300M





practice





infrastructure

35



efficiency and


Thank You

36

Clinical Decision




Interventions

CADTH



Medtronic Inc










January 2019

Findings

bull Mixed results



(11)

bull 2 RCT


evidence of harm

40

Findings



bull Wrong design




41

42

Thank You

29

References





Osheroff MD in 2012

CDS Cube



Clinical Decision



Health









33






2001 $500M


2003 $600M


2004 $100M


2007 $400M


2010 $500M

2017-2022 $300M



2016-2018 $50M


2017-2022 $300M


34

2017-2022 $300M





practice





infrastructure

35



efficiency and


Thank You

36

Clinical Decision




Interventions

CADTH



Medtronic Inc










January 2019

Findings

bull Mixed results



(11)

bull 2 RCT


evidence of harm

40

Findings



bull Wrong design




41

42

References





Osheroff MD in 2012

CDS Cube



Clinical Decision



Health









33






2001 $500M


2003 $600M


2004 $100M


2007 $400M


2010 $500M

2017-2022 $300M



2016-2018 $50M


2017-2022 $300M


34

2017-2022 $300M





practice





infrastructure

35



efficiency and


Thank You

36

Clinical Decision




Interventions

CADTH



Medtronic Inc










January 2019

Findings

bull Mixed results



(11)

bull 2 RCT


evidence of harm

40

Findings



bull Wrong design




41

42

Clinical Decision



Health









33






2001 $500M


2003 $600M


2004 $100M


2007 $400M


2010 $500M

2017-2022 $300M



2016-2018 $50M


2017-2022 $300M


34

2017-2022 $300M





practice





infrastructure

35



efficiency and


Thank You

36

Clinical Decision




Interventions

CADTH



Medtronic Inc










January 2019

Findings

bull Mixed results



(11)

bull 2 RCT


evidence of harm

40

Findings



bull Wrong design




41

42








33






2001 $500M


2003 $600M


2004 $100M


2007 $400M


2010 $500M

2017-2022 $300M



2016-2018 $50M


2017-2022 $300M


34

2017-2022 $300M





practice





infrastructure

35



efficiency and


Thank You

36

Clinical Decision




Interventions

CADTH



Medtronic Inc










January 2019

Findings

bull Mixed results



(11)

bull 2 RCT


evidence of harm

40

Findings



bull Wrong design




41

42


33






2001 $500M


2003 $600M


2004 $100M


2007 $400M


2010 $500M

2017-2022 $300M



2016-2018 $50M


2017-2022 $300M


34

2017-2022 $300M





practice





infrastructure

35



efficiency and


Thank You

36

Clinical Decision




Interventions

CADTH



Medtronic Inc










January 2019

Findings

bull Mixed results



(11)

bull 2 RCT


evidence of harm

40

Findings



bull Wrong design




41

42


34

2017-2022 $300M





practice





infrastructure

35



efficiency and


Thank You

36

Clinical Decision




Interventions

CADTH



Medtronic Inc










January 2019

Findings

bull Mixed results



(11)

bull 2 RCT


evidence of harm

40

Findings



bull Wrong design




41

42





practice





infrastructure

35



efficiency and


Thank You

36

Clinical Decision




Interventions

CADTH



Medtronic Inc










January 2019

Findings

bull Mixed results



(11)

bull 2 RCT


evidence of harm

40

Findings



bull Wrong design




41

42

Thank You

36

Clinical Decision




Interventions

CADTH



Medtronic Inc










January 2019

Findings

bull Mixed results



(11)

bull 2 RCT


evidence of harm

40

Findings



bull Wrong design




41

42

Clinical Decision




Interventions

CADTH



Medtronic Inc










January 2019

Findings

bull Mixed results



(11)

bull 2 RCT


evidence of harm

40

Findings



bull Wrong design




41

42



Medtronic Inc










January 2019

Findings

bull Mixed results



(11)

bull 2 RCT


evidence of harm

40

Findings



bull Wrong design




41

42





January 2019

Findings

bull Mixed results



(11)

bull 2 RCT


evidence of harm

40

Findings



bull Wrong design




41

42

Findings

bull Mixed results



(11)

bull 2 RCT


evidence of harm

40

Findings



bull Wrong design




41

42

Findings



bull Wrong design




41

42

42

Documents

Clinical Decision Support Systems - CADTH.ca...Clinical Decision Support in the pan Canadian Digital Health Landscape 33 • Established in 2001 as an independent, not-for-profit corporation