Decision support can help doctors order scans

by Scott Cowsill

A third or more of scans may be unnecessary or repetitive, studies show, and in scans that are medically appropriate, radiation doses could be dramatically reduced without hurting the quality of images.

As pointed out by Robert Centor, MD, “one cannot easily develop rules for testing because the presentations that we see vary so greatly.”  That being said, guidelines for diagnostic testing appropriateness have been created, are being continually updated and are proving to show significant value for patients, clinicians, healthcare organizations and the healthcare industry at large.

The American College of Radiology and other organizations such as Massachusetts General Hospital have created comprehensive guidelines that are used to provide clinicians with decision-support at the point-of-care.  These guidelines are helping clinicians to determine if they should or should not go forward with ordering a patient’s high-tech exam.  The market version of MGH’s decision-support tool, RadPort, was recently discussed in the Wall Street Journal.

These decision-support programs require doctors to enter information about a patient into the system before ordering an exam. This system is not meant to police physicians, in many cases it reinforces the doctor’s initial decision, removing any hesitancy to order.  In some cases however, the system helps to educate ordering clinicians and will redirect a physician from one exam to a more appropriate one, or to not order an exam at all.  The system does this in a very intuitive way – a yellow result, for example means that the test is questionable, meaning the value it will have on improving the patient’s outcome is not highly likely and that another test might be more appropriate.

The system also offers alternative exams.  If a scan isn’t recommended, it comes up red. At MGH, this decision support technology is used and its impact was studied from 2004 to 2009.  As part of the study, it was found that the rate of growth in outpatient scans fell to 1% a year from 12%, even though outpatient visits grew at a compound annual rate of nearly 5% over the same period.

In an article in the Wall Street Journal earlier this year, James Thrall, chairman of the American College of Radiology’s Board of Chancellors and chief radiologist at Massachusetts General Hospital in Boston said “patients should ask doctors whether a scan is necessary, what the risks and benefits are, and whether there is an alternative test that doesn’t use radiation such as ultrasound, which relies on sound waves, or magnetic resonance imaging, which uses powerful magnets and radio-frequency waves.”

In addition to patient inquiry and increases clinician/patient dialogue on this subject, clinical decision-support guidelines and technology should be explored as part of the patient care workflow.  It helps to assure the most medically appropriate patient exam is ordered.  It helps to reduce unnecessary exams by providing doctors access to evidence-based clinical guidance at the time care is being discussed with the patient. For example, if a patient comes in with a headache, and the physician is considering various tests to run, the clinical decision-support (CDS) solution will guide the doctor to order (or not order) an exam based on the patients’ symptoms, demographics and health needs.

Beyond ordering the right test for patients at the right time, clinical decision-support helps to ensure doctors are not ordering exams because they are practicing ‘defensive medicine” – ordering tests to safeguard themselves from malpractice lawsuits. According to an article published in the Boston Globe this past November, an overwhelming “83 percent of physicians surveyed said they have practiced defensive medicine and that an average of 18 to 28 percent of tests, procedures, referral and consultations were ordered to avoid lawsuits.”

Also, because more and more patients are turning to the web for medical information, physicians are faced with patients who are armed with demands for specific diagnostic imaging tests.  Aside from the obvious dangers associated with this practice, CDS has become a tool to help physicians educate the patient on the value or non-value that certain tests can deliver. The pressure that today’s physicians are faced with raises serious ethical and professional concerns that may result in suboptimal patient outcomes as well as higher healthcare costs. Again, CDS works to ensure only medically appropriate exams are ordered.

Scott Cowsill is co-founder, Imaging e-Ordering Coalition, Senior Product Manager, Diagnostic Imaging Solutions, Nuance Healthcare.

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