More than Alerts for Imaging—Clinical Decision Support As Commitment to Quality

For many, the idea of clinical decision support (CDS) begins and ends with the notion of a pop-up alert that second guesses the ordering physician’s request for an imaging exam. CDS has emerged to much more for those in imaging—less an invasive technology and more an industry-wide culture of sharing expertise and accountability.

“It’s not just an alert, it’s a set of tools,” says Jerry Osheroff, MD, principal with TMIT Consulting. “It supports people in making better decisions to achieve better outcomes.”

Osheroff has written guidebooks, led national efforts and worked with providers and other stakeholders on improving care delivery and outcomes for the last two decades. He defines CDS as a “process for enhancing health-related decisions and actions with pertinent, organized clinical knowledge and patient information to improve health and healthcare delivery.”

Osheroff developed the famed “CDS Five Rights” framework, now recommended by the Centers for Medicare & Medicaid Services as a quality improvement best practice. The framework suggests that improving outcomes requires the right information to the right person in the right intervention format through the right channel at the right time in the workflow.

He has developed tools provided by the Office of the National Coordinator for Health IT (ONC) to help providers and their partners get these CDS Five Rights in place for high-priority targets. In workshops and trainings, though, he’s noticed a level of skepticism from stakeholders.

“Three years ago, I gave talks in Louisiana at 16 different health centers and I asked them who does CDS and everyone raised their hands,” he says. “Then I asked them what CDS was and everyone answered that it was an alert system that pops up and tells you that what the ordering doctor is about to do is wrong. Then I asked them: ‘How’s that working out for you?’ and everyone laughed and shook their heads.”

To get people in the right frame of mind, Osheroff encourages participants in his workshops to look at the entire culture that surrounds the CDS mission of the right imaging for the right patient.

“You must do CDS with the stakeholders and not to them,” he says. “I have them write down what they’re doing at every step to help the patient.” Providers should systematically examine and document all the key care steps and decisions that feed into outcomes such as image ordering.

“Including the patient’s perspective and all touch points between patients and the care delivery system is key. For example, are you reaching the patient before they come in asking for certain exams so that they’re educated about their use?”

Improving Quality From Behind the Scenes

Experts like Osheroff and Safwan Halabi, MD, a radiologist from the Henry Ford Health System in Detroit, assert that supporting appropriate exam orders is very different from interrupting and second guessing a doctor with an alert.

“As radiologists, we want to do the right test and CDS offers guidance at the time of ordering,” says Halabi. “It helps save time and money for the patient, the ordering physician and the radiologist.”

Halabi led a Medicare demonstration program in 2011, partnering with the American College of Radiology, which implemented an order entry system at the hospital.

Along with co-author Joshua S. Broder, MD, Halabi published a study in the Journal of the American College of Radiology last year about the vital components needed in a CDS program.

“The shift from manual to electronic order entry for imaging studies provides an opportunity to transform imaging guidelines from a static reference to an interactive system that could provide real-time advice and recommendations to clinicians at the time of order entry,” the authors wrote.

The role of CDS, by its very nature, is a fine line between controlling radiation doses in patients and delivering the care they need.

“Clinical decision rules must achieve a delicate and difficult balance: high sensitivity (avoiding missed injury or disease) and specificity sufficient to reduce imaging utilization,” Broder and Halabi wrote.

In the study, they found that a successful CDS program is a boon for the healthcare world and not a hindrance to care.

“The ideal CDS system would reduce healthcare costs, patient radiation exposures and patient evaluation times without compromising healthcare standards or patient quality of life,” Halabi and Broder wrote in their study.

In their article, they wrote that effective CDS methods can be behind-the-scenes and flexible, with the ability to seamlessly import a patient’s EHR and giving the ordering physician access to the information instantly.

Furthermore, Broder and Halibi contend, effective CDS systems should be automated to bring decision support to the physician at the time of the order, making it compatible with the physician’s workflow.

They cited early CDS adopters like Massachusetts General Hospital (MGH) and Brigham and Women’s Hospital, both in Boston, that retrofitted CDS guidelines into their ordering systems.

“Initial results at MGH demonstrated a decrease in low-utility examinations from 6 percent to 2 percent,” they wrote. “Statewide initiatives in Minnesota using imaging CDS have demonstrated that the number of high-tech scans did not increase in 2007, compared with an 8 percent increase in the prior year.”

Furthermore, the article asserted that institutions that adopt CDS will benefit the most from government incentives, while avoiding penalties for adhering to appropriateness guidelines.”

Group Effort

Finding success in implementing a CDS program lies in the organization as a whole, according to Halabi.

“First, there has to be a will or a culture of wanting to do this type of quality project,” he says. “And what’s difficult is that you’re basically telling people not to image and that means less money. But when you give patients the correct image, it really pays off in a lot of ways both in terms of their health and financially. It’s quality of care and it’s cost saving.”

As far as achieving a successful CDS program implementation, Richard Duszak, MD, vice chair for Health and Policy Practice with the Emory University School of Medicine in Atlanta, sees a few stumbling blocks along the way.

“There are lots of different costs and interface issues that organizations have to face and there will be even more the farther down the path we go as an industry with new technologies and requirements,” Duszak says. “But the farther down the path we do go, the more we’ll be able to assist radiologists, patients and physicians in getting more bang for their buck.”

Aligning incentives is another challenge Duszak sees in successful CDS programs, as different incentives make forward progress challenging. One example he cites is the self-referral phenomenon.

“There’s good data out there to indicate that when a referring physician owns his or her own imaging equipment, you’re more likely to get that type of imaging,” he says. “When you go see a doctor for knee pain and that family physician doesn’t do imaging, you’re likely to get a referral. If that physician owns x-ray equipment, you’re more likely to get an x-ray before you’re out the door. One way to look at it is, if the only tool you have is a hammer, everything starts to look like a nail.”

Duszak believes that CDS programs could assist patients in avoiding imaging exams that aren’t necessary or helpful. For physicians, Duszak sees CDS as a way to open dialogue between themselves and radiologists.

“If you have a system that gives you a red alert when you input an exam, the doctor might think the test shouldn’t be done. If it’s a green, it’s like getting the ‘go ahead,’” Duszak says. “But the yellow alerts, to me, are a huge opportunity to go beyond CDS just being a computer program. In my fantasy utopia, this would be a chance for the physician to have a chat with a radiologist to help them drill down the best approach to the patient’s care as a team.”

Duszak sees the teamwork approach of CDS programs as a way for radiologists to avoid commoditization.

“A knee jerk reaction is that CDS is just a software solution and my message to them is that if you want to just read your x-rays alone in your office, you’re setting yourself up for commoditization,” he says. “If you see it as a support tool, if you look at this as a way to get the right answer to the physician, you maintain relevance.”