S

Clinical Decision

Support SystemsRachel Bayles Lacey

Current Research

S Clinical decision support systems for utilization of CT in

the emergency department

S Authors: Ivan K. Ip and Frank S. Drescher

S Imaging in Medicine. 4.6 (Dec. 2012): pg. 605

Primary Question

S How have clinical decision support systems impacted

diagnostic imaging?

S X-rays

S Computed tomography (CT) scans

S Nuclear medicine scans

S Magnetic resonance imaging (MRI) scans

S Ultrasound

Risk of Overutilization

S Increased cost

S US$11.4 billion Medicare beneficiaries (2007)

S Increased radiation exposure

S Estimated 29,000 cancers a year in the U.S. are related to

CT scans

Overdiagnosis

S Unnecessary follow-up imaging

S Additional unnecessary procedures and treatments

S Finding many “false positives” which increase stress for

patient

Non-medical Reasons

S Doctors order more tests to cover their liability (defensive

medicine)

S Financial incentives to order more test and more

procedures (physician self-referral)

S Traditional “symptom” checking not being taught in

medical school

CPOE/CDSS

S Computerized physician order entry (CPOE)

S Provide instructions for patient care

S Embedded clinical decision support system (CDSS)

S Provides alerts and/or reminders

S Wide range of options

S Hard stops that prevent order altogether/require override

S Simply educational

CDSS

S Shown to improve physician performance, safety, and

outcomes

S Improvements

S Diagnosis

S Preventive Care

S Disease management

S Drug dosing and prescribing

Why imaging in ED?

S Many clinical decision rules have been developed and

validated

S Canadian CT head rule

S New Orleans criteria

S Ottawa ankle and knee rules

S NEXUS for cervical spine imaging

S However, policy has not translated well into clinical

practice

Why imaging in ED?

S Increase in medical imaging most evident in emergency

department

S Use of CT/MRI for injury-related conditions

S 6% in 1998

S 15% in 2007

Clinical Prediction Scores

S Need strong evidence

S Translatable to actionable automated decision support

S Wells Criteria

S venous thromboembolism

CDSS Intervention

S Overall reduction in inappropriate diagnostic imaging for

suspected PE

S Pre-intervention

S 35% not adherent to guidelines

S Post-intervention

S 22% not adherent to guidelines

CDSS Intervention

S Before implementation

S Quarterly use of CT rose 82.1%

S 14.5 to 26.4 CT scans/1000 patients

S After implementation

S Quarterly use decreased by 20.1%

S 26.4 to 21.1 CT scans/1000 patients

Study was over a period of six years

Unnecessary radiation

S Passive reminder

S Patient has received more than five CT scans within the

prior 365 days

S Showed no significant change in physician ordering

habits

Effective CDSS

S Speed

S Anticipation of needs and delivery in real time

S Fitting the users’ workflow

S Usability

S Recognition of physician resistance

Effective CDSS

S Altering rather than stopping behavior

S Simplicity

S Minimum amount of information

S Monitoring and maintaining knowledge-based systems

Effective CDSS

S Concise

S Context specific

S Relevant to clinician’s current decision

S Provide a recommendation rather than just an assessment

S Justification of decision support by providing research evidence

S Promotion of action rather than inaction

Most persuasive forms of

evidence

S Peer-reviewed literature; particularly those that include

S Decision-making rule

S Cost-effectiveness analysis

S Practice guidelines

S American College of Radiology Appropriateness Criteria

S American Heart Association Cardiac Imaging Guidelines

S http://www.acr.org/Quality-Safety/Appropriateness-Criteria

S Easily translatable to context-specific actions/not vague reminders

Organizational Culture

S Quality

S Safety

S A clearly stated vision from the highest levels of the

organization

Reasons for lack of high

quality evidence

S Researchers is at intersection of fields

S Outcomes research

S Implementation research

S Systems redesign

S HIT changes at rapid pace

Barriers

S Financial barriers to CDSS implementation

S Physicians' resistance to CDSS

S Interoperability issues

S Fee-for-service provides financial disincentive to

decrease number of imaging procedures

Questions

S Where should the responsibility ultimately lie for making a

decision about image ordering?

S Physicians?

S Patients?

S Hospital Administration?

S Clinical Decision Support System?

S Insurance Providers?

S Taxpayers?

Questions

S Would you personally be more concerned with excess

radiation exposure or with a misdiagnosis?

S For potential tumor?

S For chest pain?

S For leg swelling?