E-ordering system reduces low utility exams

A system that required physicians, rather than support staff, to approve low-utility imaging exams was able to cut their incidence by more than half, according to a study from Massachusetts General Hospital reported Sunday at the 2009 RSNA meeting.

Low-utility exams fell from 5.43% of those approved to 1.92% in before- and after-system changes monitored over sequential nine-month periods at MGH, said the principal researcher, Dr. Vartan Vartanians.

The utility ranking system used at MGH mirrors the American College of Radiology's Appropriateness Criteria. Imaging studies entered through an e-ordering system are ranked on a color-coded, 1 to 9 scale based on how likely they are to yield information that would shed light on the clinical question posed by the requesting physician. High-utility exams are coded green and get a 6 to 9 ranking. Low-utility exams are coded red and get a 1 to 3 ranking.

The researchers ran a nine-month control period beginning in April of 2006, collecting data from 42,000 exams. They then implemented a system prohibiting support staff from ordering the low-utility exams and repeated their survey over a nine-month period beginning in April 2007, collecting data on approximately 76,000 exams. Low-utility exams could still be ordered by physicians.

Among their findings:

• Ordering of exams by nonphysicians fell from 74% before the new system was implemented to 46% after.
• Among clinicians, those who decided not to proceed with the scan went from 24.4% to 38.5%. Those who decided to modify the exam (alter the indications or change the exam) went from 14.9% to 14.6%. Those who decided to proceed with the exam fell from 60.6% to 48.7%.
• Among nonphysicians, those who decided not to proceed with the scan went from 8.3% to 48.7%. Those who decided to modify the exam (alter the indications or change the exam) went from 10% to 35.2%. Those who decided to proceed with the exam fell from 81.6% to 7.5%.

Vartanians was asked whether there were complaints from clinicians about the new system. He acknowledged that there most likely were, but said the percentage was probably small. In addition, the new system came with offsetting advantages including less paperwork and fewer phone calls for approval.

"I think we made their lives easier," he said.