CDS and physician engagement: Improving radiology utilization

Providers are adjusting to the fact that not only are they assuming greater risk for care costs, but their patients are also taking on more of the financial responsibility, all while payers expect greater care value. All of this places increased pressure on more effective utilization of care resources. A large, technologically-innovative hospital system recently addressed this dynamic in computerized tomography (CT) imaging. This hospital system's experience highlights the importance of leveraging a clinical decision support (CDS) platform to drive enduring, beneficial change in physician care.

A framework for improvement
The hospital system began a project in 2012 to improve radiology efficiency. The effort focused on CT head scans for non-traumatic headache, with twin goals of improving quality and reducing unnecessary CT scans that didn't bring value – and could potentially harm patients through unnecessary radiation exposure. For study purposes, the project was conducted at a control group of hospitals within a single, major metropolitan area, all using the same advanced CDS system.

Protocol refinement and implementation
The hospital system's medical leadership adapted the CDS system's protocols to existing practices. The required modifications were minor, as prompts were to act as reminders to adhere to established protocols that may not have always been followed.

Protocol refinement was conducted simultaneously with server installation and data feed connection. Deployment followed development and testing, and the level of IT effort required was minimal – approximately six weeks of part-time effort from one coordinator and two analysts focused primarily on infrastructure and data mapping. The actual roll-out was extremely non-disruptive. Two weeks before go-live, clinicians were introduced to the CDS system with a ten-minute tutorial.

Point-of-care interventions within existing workflows
Integrated with the hospitals' existing EMR, the CDS system read structured and unstructured data in real time, applying best-practice protocols and providing alerts to clinicians regarding CT imaging orders. The system monitored EMR entries unobtrusively, comparing them with the patient's clinical data from other systems and with evidenced-based clinical guidelines and protocols.

In this role, when the CDS system detects an opportunity for corrective course, it delivers a pop-up alert, though it is up to clinicians to determine the appropriate response to an alert - change an order, enter documentation justifying the order or ignore the alert. CDS system reports indicate the action taken for each alert.

Lasting behavior change and outcome improvements
The first three months' focus consisted of reviewing daily CDS reports with clinicians to understand when responses to alerts indicated a need to adjust protocols, and when they suggested the need for changes in clinical practice. Having near real-time reports was essential in reinforcing change, as the care in question was still fresh in the clinician's mind at the time of reviews.

While some protocol refinements resulted, the primary CDS impact over the first 10 months of utilization was a dramatic increase in best-practices compliance. The total number of monthly alerts steadily fell from 339 to 198, with total monthly alerts bypassed falling from 113 to 22, for a reduction in an average rate of non-compliance from 33 to 11 percent.

By the conclusion of the study, approximately two-thirds of bypassed alerts were instances in which the clinician should have considered the alert's recommended best practice. In the remaining one-third, clinical documentation was inaccurately recorded.

Outcomes and acceptance
The increase in best-practices compliance greatly reduced duplicate and inappropriate head CT scans. Duplicate scans were virtually eliminated, and scans deemed inappropriate were reduced from as much as 23 percent to less than 5 percent across all participating hospitals. These gains led to significantly fewer claims denials and increased revenue, with sustained results.

Clinician feedback was positive, with praise for information delivery within workflows and evidence-based algorithms. Additionally, clinicians welcomed the fact the alerts did not disrupt their workflows or require them to double document information, thus leading to an even greater appreciation and optimistic experience with the new system.

Moving forward
The program has also been expanded to cover CT imaging for all headache, chest and abdominal pain patients, and initial measures of cost savings and improved utilization in these uses are consistent with those of the initial project. The system as it exists now is expected to meet CMS Protecting Access to Medicare Act (PAMA) requirements as a CDS tool to determine appropriate use in ordering radiology studies.

Much of this progress is due to the hospital system's culture of encouraging innovative thinking and early adoption of point-of-care technologies for clinical outcomes – an essential element of leveraging new solutions for full realization of the purposes for which they have been created.

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