The document discusses the use of clinical decision support (CDS) systems to improve the appropriateness of radiology orders and utilization of imaging exams. It describes how CDS can integrate patient data, rules engines, and medical knowledge to produce patient-specific recommendations at the point of order entry based on standards like the ACR Appropriateness Criteria. The document outlines some of the challenges of CDS implementation as well as strategies used in a pilot at the Mount Sinai Medical Center to provide clinicians with feedback to improve their imaging ordering patterns over time.

1. IMAGING INFORMATICS: IHE
RADIOLOGY ORDER ENTRY CLINICAL
DECISION SUPPORT
Based on the RSNA 2014 presentation, December 2014
Written by: David S. Mendelson, M.D.
Professor of Radiology
Senior Associate- Clinical Informatics
The Mount Sinai Medical Center
Co-chair IHE International Board
Adapted and presented for the
IHE Colombia IHEWorkshop by:
Elliot B. Sloane, PhD, CCE,
FHIMSS
Co-chair IHE International Board
President, Center for Healthcare
Information Research and Policy
(CHIRP)

2. Radiology Orders
 The right order
 The right reason for
exam and background
information
 Automated scheduling
 Pre-defined Procedure
steps at the modality
 Uniformity of exam
 Radiology Order Entry
Clinical Decision Support
 Standard Exam
dictionary
 RADLEX Playbook
 ModalityWorklist
 Standard Protocols
mapped to a modality
 RADLEX Playbook
 Series pre-defined
What do we need? Enablers

3. Radiology Orders
 Appropriateness
 Cost Control

4. Radiology Order Entry
Clinical Decision Support
 Ensure the correct order based upon
standardized rule sets
 Utilization control
 Inappropriate Utilization
 Redundant Imaging
 Replacement for Radiology Benefit Managers
 Education for the clinician
 Compare their ordering metrics to their peers

5. Inappropriate Utilization
 Defensive Medicine – Liability concern
 Tort Reform
 Patient Demand
 Financial Incentives
 Self referral
 Pressures to minimize overall cost of an episode of
care
 Physician lack of knowledge
 Duplicate exams
 Results not easily available
 Patient lack of understanding of exams already performed
 Fragmented care – no coordination of care
Up to 20% of imaging exams may be inappropriate

7. Iglehart JK. Health Insurers and Medical-Imaging Policy — A Work
in Progress. N Engl J Med 2009;360:1030-1037

8. A Roadmap for National Action on
Clinical Decision Support-June 13,
2006

9. Decision Support
 Collegial advice
 Text references
 Web sites
 Computer systems
 Passive
 Active
 Alerts
 Reminders
 CorollaryOrders
 Guidelines

10. Clinical Decision Support
Systems (CDSS or CDS)
 Incorporates
 Patient data (EHR)
 Rules Engine
 Medical Knowledge
 Produces a patient specific recommendation

11. Clinical Decision Support - CDS
 CDS is a technology that may help to
significantly improve the appropriateness of
orders through dissemination of Comparative
Effectiveness Research (CER) to clinicians at
the point of order-entry.

12. American College of Radiology
Appropriateness Criteria (ACR AC)
 A formal mechanism to determine the utility of
imaging exams to diagnose disease
 Evaluate existing evidence comparing candidate
modalitites
 Synthesize a utility index
 Rand/UCLA Appropriateness method
 Evidence
 Consensus
 Limitation – evidence is generally not on double
blinded randomized studies

13. Radiology Benefit Managers
 RBM services to obtain pre-clearance for high
cost procedures
 Effectively Diminish Utilization
 Issues
 Burden of a frustrating time consuming solution
with a significant cost in manpower
 Implementation
 Is this done rationally?

14. CDS- some data
 Pilot study in Minnesota with members of
Institute for Clinical Systems Improvement (ICSI)
 Imaging growth was curbed while
simultaneously improving the rate of indicated
examinations (ambulatory environment
 Added benefit was that while RBM pre-
certification required an average of 10 minutes of
interaction, the CDSS only required 10 seconds
 Efficient workflow and scheduling, with a diminished
need to reschedule patients

16. Decision Support
 Clinician
 Radiologist
ACR – National Decision Support
Clearinghouse

17. EMR
CPOE
Radiology
CDS
Radiology
RIS
HighAppropriateness
score

18. EMR
CPOE
Radiology
CDS
Radiology
RIS
HighAppropriateness
score
Low
Appropriateness
Score-Try Again!

19. Radiology Order Entry
Clinical Decision Support

20. Imaging 3.0: A Framework for Radiologists’ Future

21. Utilization Management 3.0
• Drive towards appropriate
utilization of imaging
– Ensure value of proper
imaging (and the
Radiologists role) is
defined as valuable
– Right test, right time,
properly performed and
interpreted
– Create a platform and
tools to promote the value
of imaging

22. Utilization Management and Value based
Radiology
Bob Cooke

23. Decision Support System
• The ACR Appropriateness Criteria ® must
become a “digitally consumable” DSS to be used
as part of a Clinical Decision Support System
• The ACR has formed a commercial entity so that
the AC® can be used to integrate this
“knowledge base” into CDS systems
23

24. National Decision Support Company
• The ACR manages the content of the knowledge
base. NDSC is the exclusive agent of the ACR
for delivery of the content into the market
• NDSC is the commercial entity to manage the
delivery and integration of this knowledge base
into CDS systems
24

25. ACR’s Role
• Curates the clinical content based on market feedback
obtained by NDSC, development of new imaging
procedures, and member feedback.
Aggregate user experience
Content Updates Market Feedback
New Releases

26. CDS- Challenges
Issue Definition Approach to Resolution
Alert Fatigue users begins to ignore (white noise) or override
alerts due to a high frequency of alerts
Content domains and triggers for the selected Imaging
CDSS
Overriding CDSS interventions
that appear all too frequently,
Assess local practice and correct if necessary; re-assess AC
Delivery to the wrong population Delivery of CDS to the correct user population
also impacts adherence and success
Selectively turn off CDSS for certain category of clinicians.
Appropriateness Criteria is
incorrect
Accuracy of CDSS is a critical factor in CDSS
success
Review and correct in system. Feedback to clinical staff
Game the system Enter inaccurate information merely to obtain
approval for desired examination
Look for disproportionate utilization even if seemingly
justified. Check if rules never trigger. Counsel offenders
(?Penalize- last resort)

27. Close the loop
 Measure each clinicians performance
 Communication
 Compare anonymously to peers

28. Mount Sinai Experience
 Data Collection Phase
 System is in place with discrete orders
 No feedback
 Determine Baseline performance
 Presentation state is important
 Change management
 Utility scores of 1-3
 Consistently 8%
 Educate
 Plan – turn on feedback