Clinical Decision Support in Radiology: Its Time Is Now

There’s been a great deal of discussion in recent years about using clinical decision support (CDS) systems to ensure that imaging studies ordered and performed are appropriate. But the use of such systems in radiology isn’t a new idea. For the past decade providers and policymakers have discussed the proper use and implementation of CDS programs.

In the December issue of the Journal of the American College of Radiology, Hanna Zafar, MD, assistant professor radiology at the Hospital of the University of Pennsylvania, discussed the history, benefits, and challenges associated with CDS systems in radiology. Diagnostic Imaging spoke with her about this paper.

Why did you decide to take a look at all the legislation that includes or impacts clinical decision support?

We were trying to convey that the policies regarding clinical decision support addressed in the American Recovery and Reinvestment Act (ARRA) did not appear overnight but were built on a long legislative history. Since 2003 policymakers have been interested in the use of CDS both for health care in general, as well as public reporting and radiology through the use of financial incentives and penalties. ARRA builds on the foundation established by this prior legislation in order to try and improve the quality, deliver and reporting of imaging procedures.

What are the major benefits of using CDS? What is the impact?

It’s important to understand that the implementation of CDS in imaging is part of a continued pattern to improve the quality, delivery and reporting of imaging procedures. Imaging CDS was not created to penalize radiologists or target imaging negatively. It is also important to remember that CDS is only applicable to those situations where evidence based guidelines exist.

CDS provides several benefits to clinicians, radiologists and patients. The chief benefit to clinicians is that it educates providers on evidence-based guidelines relating to imaging at the time of image order entry. That last phrase is critical because although many excellent guidelines exist, it’s not feasible for clinicians to refer to those guidelines at the time of ordering an imaging examination. The fact that these guidelines can be distilled into key clinical questions allows the system to interact with and give feedback to the provider in a seamless manner. Imaging CDS can also reduce inappropriate or redundant studies by providing alternative imaging procedures that are better suited to answer a clinical question per evidence-based guidelines or by highlighting the results of prior, potentially relevant, imaging procedures to help reduce redundant testing.

CDS also provides several benefits to radiologists. On a concrete level, it requires the input of relevant and pertinent pieces of clinical history into the physician order entry at the time of the clinical study order. If available to radiologists at the time of study interpretation, this clinical information can be extremely helpful in how we evaluate and interpret reports.

Specifically, this clinical data can help us to better understand why a clinician is ordering a study and to ensure that our report answers the critical clinical question for the provider and the patient. Reduction of inappropriate and redundant testing is also beneficial to radiologists in that it allows us to focus on appropriate imaging procedures. Radiologists, similar to other specialties, want to improve patient care through the optimal use of diagnostic imaging and of health care resources.

Finally, from the patient perspective, imaging CDS can improve patient safety through avoidance of unnecessary radiation from inappropriate or redundant procedures and the effect of unnecessary downstream procedures, such as the management of incidental findings.

On a more global note, imaging CDS offers a very exciting and novel opportunity to tie utilization of evidence-based imaging guidelines with patient outcomes. Imaging-related outcomes have long been a grey zone for radiologists because we don’t order imaging procedures, and we often don’t have easy or reliable access to relevant clinical history. Access to outcomes data will be valuable for us as radiologists, and it will be increasingly important for future policy and legislative decisions.

Are there challenges to implementing a clinical decision support system on a large scale?

The success of imaging CDS in reducing inappropriate imaging procedures thus far has been demonstrated in single institutional or health system studies and within a handful of states. We are optimistic that these results can be replicated on a larger national scale. However, this remains to be seen. An important point to remember is that even though there are no guarantees that imaging CDS utilization will translate necessarily or easily into improved quality and outcomes, it will bring us closer to understanding the relationship between guidelines and patient outcomes. This knowledge will allow us to begin to improve imaging utilization.

As for challenges in imaging CDS implementation, there are several that we can anticipate and others that we will likely have to address as they come. One of the main anticipated challenges is that imaging CDS relies on the existence of high quality guidelines. To date, imaging CDS has focused on clinical areas involving such guidelines as the use of lumbar spine MRI for lower back pain or CT pulmonary angiography for suspected pulmonary embolism. However, there are many imaging procedures that involve clinical scenarios for which we don’t have high quality guidelines. This will be an obstacle.

Another challenge for imaging CDS is variability in practice patterns among geographic regions, specialties and even individual providers. For some clinicians, imaging CDS is perceived as “cookie-cutter medicine” or a waste of time. There will always be some degree of resistance to any change in medicine, but nothing powerful enough to deter the need to explore the potential of imaging CDS to improve the deliver of radiology procedures.

How is CDS more beneficial than a pre-authorization program?

One of the key benefits of imaging CDS is the convenience. Most pre-authorization programs require that for specific type of imaging orders, physicians must speak on the phone with a representative, who may have variable levels of clinical expertise in the clinical area in question, in order to get approval for a study. Typically this representative will ask questions regarding relevant past and current medical history that prompted the desired imaging exam and how the exam will help.

Although most of these companies also use some form of guidelines, transparency and quality of these guidelines is not always shared with the ordering provider. In addition to the time it takes the ordering clinician to get on the phone and interact with the provider, they may have to wait for a call back if the representative is not able to give an answer.

Contrast this with imaging CDS where, right at the time of image order entry, the system can obtain the necessary relevant history, provide the ordering clinician with evidence-based recommendations, as well as results of related prior imaging studies that may reduce redundant imaging and, in some cases, provide data on cumulative radiation dose from prior imaging studies. As such, imaging CDS is perceived by many ordering physicians to be more efficient than pre-authorization programs.

Imaging CDS also offers an educational opportunity to ordering physicians at the time of order entry. Specifically, most systems will provide feedback in four categories: appropriate, inappropriate, uncertain, and outside of guidelines. Ordering physicians are informed which guidelines were used to derive this feedback and, with the click of a button, can even review the guidelines in question again at the time of order entry. In the case of inappropriate studies, imaging CDS can recommend alternative imaging studies that may be more appropriate.

It should be noted that the choice of how to use imaging CDS is institution specific. While some institutions provide feedback but do not prohibit providers from ordering inappropriate studies, others may have a “hard stop” so providers are unable to order inappropriate studies without a peer-to-peer consult with a radiologist or other mechanism. Again, the difference in this scenario compared to pre-authorization is that the phone interaction may only be required after it is established that the examination is not appropriate per evidence-based guidelines.

As implementation continues to spread, what will be the economic implications?

It is difficult to determine the economic outcome of imaging CDS. The focus of imaging CDS is to reduce inappropriate, unnecessary or redundant imaging. In some cases this may be associated with cost savings, but not necessarily. For example, in a predominantly fee-for-service environment the cost associated with purchasing imaging CDS software, which is costly, may not net a positive return on investment as this system will reduce utilization and, therefore, revenue.

However, in those situations where payment shifts to make providers responsible for the quality rather than quantity of care - like accountable care organizations - or in those situations where payers are willing to forgo pre-authorization programs in exchange for imaging CDS, health care institutions may find CDS systems to be profitable.

Another possibility is that even in a fee-for-service environment if CDS is integrated into support staff workflow, such as online scheduling, reductions in inappropriate imaging could be replaced with an equal volume of appropriate imaging, netting no change in study volumes. The bottom line is that the purpose of imaging CDS is to curb inappropriate imaging. We suspect that this will translate into more cost-effective utilization of imaging. However, that remains to be seen.

What will be the fall out if referring physicians resist using a CDS?

Imaging CDS systems are targeted towards physicians ordering imaging procedures. Given the rapid rise in outpatient imaging demonstrated in the first half of the last decade, the fact of the matter is that payers are becoming more and more interested in the use of methods to curtail perceived inappropriate imaging in order to keep tabs on the bottom line. Most payers have begun to use some form of pre-authorization for imaging procedures and the question remains to be seen whether they will settle on a single method or allow more of a salad bar approach whereby providers and systems can select from among several options.

Seen from this light, providers have a vested interest in finding a palatable method of maximizing appropriate imaging studies so that we can advocate to payers what methods we prefer. It’s a bottom-up approach rather than waiting for payers dictate a method to us - more of a top-down approach.

Prior experiences, for example in Minnesota, demonstrate that providers prefer imaging CDS over prior authorization because it’s efficient and provides an educational component to providers about which imaging examination has the highest utility for a given medical condition. As radiologists, we need to be at the forefront in developing alternative methods to optimizing imaging utilization since we are among the most knowledgeable on the appropriate use of imaging, and it directly affects our workflow.