Appropriateness. This word represents the fundamental principle behind the value of clinical decision support (CDS) tools for the ordering of radiology exams. If an imaging examination is not an appropriate next step in the workup of the patient, why order it? If another type of study is more likely to produce better results – or exposes a patient to less radiation – or is less expensive, why not consider it as an option?
Best-practice guidelines are most dependable when one is confident that they are both evidence-based and current. The American College of Radiology (ACR), which now has spent over two decades developing best practice guidelines, is the first to state that all require regular, timely review – updated as needed to stay meaningful and relevant. But no matter how current, appropriate, and vetted, guidelines frequently require customization to match local practice patterns. In addition, no matter how valuable they may be, they are not useful if they are not readily available.
Customization adds relevancy. Ease of use promotes use. Both of these capabilities are essential to evaluate when selecting a commercial system to implement by January 2017.
New IT technologies, no matter how beneficial they have the potential to be, generate concern and meet with a level of resistance. Think about the experiences of implementing RIS, PACS, speech recognition dictation systems, structured reporting templates? About structured reporting templates– has your radiology department or practice adopted these yet? If not, why not? Good technology tools exist. The RSNA has a library of several hundred free of charge best-practice reports developed by experts available for download.
Both structured reporting and CDS require physicians to change how they have been practicing. They represent conformity and standardization in the practice of medicine. This can be hard to accept. An attitude of acceptance is essential for either technology to succeed. And what this means is that neither are simply “plug ‘n play”.
Which leads us to the point of this column: Advance planning is a major key to success. Take some advice from successful structured reporting initiatives. Pluck low-hanging fruit first, show the benefits, and build upon that to get buy-in, add champions, and escalate momentum.
- Identify one or several respected individuals willing to lead a project.
- Within the radiology department, anecdotally discuss what examinations yield the least beneficial results and what examinations radiologists believe are the most inappropriately ordered or the most over-ordered.
- Discuss internally what situations physicians call the radiology department for advice on what types of imaging exams to order. Talk with referring physicians themselves. The emergency department is a good place to start.
- Encourage technologists and department staff to identify workflow issues that could be improved upon by a CDS tool.
- Run analytics to verify assumptions. Select a workable number of examinations to target first.
- Read the associated ACR guidelines. Determine if these work as written for your organization, or if modifications and exceptions are needed. If so, identify and specify these. Distribute for comment and to achieve consensus, reaching out and soliciting the opinion of departments within a hospital or physicians outside it who order the most of these exams.
- Identify all the referring entities that need easy access to your decision support, even if they are not using your EMR. Incorporating their needs will ensure that these valuable referrers will continue their referral streams to you.
The foundation of most commercially available CDS systems – including MedCurrent CDS – is based upon ACR guidelines (although other options may become available once CMS publishes their rules this summer). But like PACS, each system is differentiated. When evaluating systems to purchase, it is imperative to scrutinize features and ease of functionality, specifically the ability to customize and to create unique rules, the simplicity and ease of use for an ordering physician, analytics functionality, and the ease of generating customized reports.
Aim for the goal of 2016 as a launch date for radiology CDS, preferably as early in the year as possible. A gradual rollout is easier for everyone involved. Time enables rules to be tweaked, human resources not to be overstrained, and successes to be documented and promoted.