Clinical Decision Support and Quality Improvement

Clinical decision support (CDS) is required to meet the upcoming PAMA (2014) mandate for radiology, so practices are going to need a CDS system in order to be compliant and be paid for the care they provide to Medicare patients.

But are there other benefits of using a CDS? Specifically, can a CDS contribute to improved patient care? Can this be measured?

Well, if one considers a reduction in the ordering of inappropriate studies as a measure, then the answer to these questions appears to be a definite ‘Yes’.  Let's look at a sampling of the literature on this topic – quite a few studies on the subject have been published in peer-reviewed journals over the past few years.

In 2011, Blackmore et al[i] found that CDS (with denial of imaging for inappropriate requests) reduced lumbar MRI for low back pain by 23.4% and sinus CT for sinusitis by 26.8%.  In another study, taking place in the Emergency Department, Raja et al[ii] noted that CDS use was associated with a 20.1% reduction of CTPA for suspected acute PE (from 26.4 examinations per 1000 patients to 21.1).  This reduction was also associated with an increased positivity rate of 69% (from 5.8% prior to CDS use to 9.8% afterwards) demonstrating an improved yield in those studies that were considered appropriate.

In another example, at a site using the MedCurrent CDS system, a reduction in inappropriate use of CTPA for PE was noted, with inappropriate ordering decreasing from 35.2% to 22.6%.  Similarly, inappropriate imaging for headache improved from 29.5% to 23%.

There are numerous papers on this topic but the conclusion is clear: CDS can help contribute to a practice’s Quality Improvement (QI) program by reducing the ordering of inappropriate medical imaging studies.

This QI is also important when considering reduction in radiation exposure to patients, especially children.  In a double-blind randomized simulation reported by Bunt et al[iii] on family physicians assessing pediatric patients with hematuria, ordering doctors were presented with radiation exposure information in addition to imaging-appropriateness guidelines.  The authors concluded, “Decision support during a simulated pediatric scenario helped family physicians select imaging that lowered radiation exposure and was aligned with current guidelines.”

Another benefit to be considered, for those institutions wanting to maximize their EMR Adoption scores, is that a good CDS system helps to achieve Meaningful Use Stage 4.

In summary, a CDS system can help significantly with a hospital’s Quality Improvement program by reducing the utilization of inappropriate medical imaging studies, including a reduction in unnecessary exposure to ionizing radiation.  So while the PAMA (2014) mandate is coming and will require the use of a CDS system, significant benefits for the use of such a system are already available today.


[i] Blackmore CC, Mecklenburg RS, Kaplan GS. Effectiveness of Clinical Decision Support in Controlling Inappropriate Imaging. J Am Coll Radiol 2011;8:19-25.

[ii] Raja AS, Ip IK, Prevedello LM, et al.  Effect of Computerized Clinical Decision Support on the Use and Yield of CT Pulmonary Angiography in the Emergency Department. Radiology 2012; 262(2):468-472

[iii] Bunt CW, Burke HB, Towbin AJ et al.  Point-of-Care Estimated Radiation Exposure and Imaging Guidelines Can Reduce Pediatric Radiation Burden.  J Am Board Fam Med 2015;28(3):343-350