Imaging Technology News - November/December 2008 - (Page 46)

Feature DECISION SUPPORT When is Appropriateness Criteria Appropriate? Can decision support tools both help and hinder radiology workflow? By Cristen C. Bolan Photo courtesy of Siemens Medical Solutions ecision support for radiology is designed to benefit the radiologists, hospitals and the healthcare system in several ways by improving patient outcomes, decreasing healthcare costs and urging providers to take part in pay-for-performance (P4P) initiatives. However, decision support has not been readily embraced without some resistance. There are several types of decision support tools, such as clinical knowledge, data mining and virtual collaboration, but what is shaking up the radiology community the most is the image appropriateness criteria requirements. While the new set of guidelines are designed to assure only appropriate imaging exams are ordered, this approach imposes an added layer of bureaucracy onto an already cumbersome healthcare system. In addition, conflicts arise when a radiologist’s order is denied based on a third-party decision made by a nonphysician. Will this type of decision support, many clinicians wonder, help or hinder the radiologists’ workflow? D ical test results is often manual and prone to error. To address the need for effective delivery of critical information, a CTRM solution developed by Vocada, a company acquired by Nuance last year, streamlines communication between radiologists and referring physicians, reportedly reducing the time in which it takes a critical test result to be communicated. In the short term, we should expect to see more data mining tools, such as the REMIND Clinical Insurers are driving the adoption of appropriateness criteria as a means to curb utilization costs of imaging exams. Decision Support (CDS) application developed by Siemens Medical Solutions and MAASTRO (Maastricht Radiation Oncology). The REMIND platform (Reliable Extraction and Meaningful Inference from Nonstructured Data) includes data extraction such as natural language processing and proteomic analysis, data combination and probabilistic inference. The solution searches through all patient records, analyzing demographics, clinical factors, imaging information, treatment plans, delivered treatment, genomics and proteomics. Philips Healthcare is testing a decision support solution for the evaluation of dementia that using libraries of FDG-PET brain-scan images that had already been independently interpreted by an expert. The software analyzes PET brain-scan images and combines them with MRI (Magnetic Resonance Imaging) scans to detect the characteristic patterns of brain diseases such as Alzheimer’s, Frontotemporal Dementia and Lewy Body Dementia. It then quantifies the degree to which they resemble reference images of known dementia sufferers. Decision support tools are viewed as another tool that a doctor can use in addition to a stethoscope and X-ray. Spread of Decision Support Tools Decision support is an emerging market and the technology within clinical decision support is varied. Online reference tools, providing access to medical journals, falls under the clinical decision support umbrella and to date has been widely adopted. “Currently, the most commonly used decision support tools are online medical journals,” according to Datamonitor Research Analyst Christine Chang. “A lot of companies will take all of the research on a certain topic and drill it down into a one-page format so that it is easier for doctors to read. Then if the doctors want more information later, they can go to the actual studies.” Also commonly implemented are the alerts and reminders embedded in CPOE systems. “With CPOE, if they are prescribing medication, an alert may pop up saying the patient is allergic to it,” Chang said. Another area where decision support promises to improve not only the radiologists’ workflow but also patient care is with critical test result management (CTRM). Critical test results – for example, cancer found while reviewing a CT chest scan – are communicated from the radiologist to the physician and, next, to the patient. According to a survey by the Joint Commission, 58 percent of healthcare organizations fail to meet the standard for effective communication of critical results. The current process for delivering crit46 | ITN | Nov/Dec 2008 | ITNonline.net avoid unnecessary utilization. Even more importantly, by changing the way diagnostic imaging exams are ordered, ideally cancers associated with diagnostic CT scans might be reduced. Derived from the American College of Radiology (ACR) Appropriateness Criteria, and designed in conjunction with Massachusetts General Hospital (MGH), a “utility scoring” methodology that determines the appropriateness of each imaging exam based on clinical information (provided by the referring physician) and patient demographics is getting a lot of attention. MGH added this decision support tool, called Radport, to its radiology order entry system (ROE). The ROE provides information to medical practices on utilizing radiology exams in their most efficient manner. Built on 3,000 rules from the ACR rule set, the system operates with a utility score designed to limit proliferation of low utility examinations, justify the appropriateness of exams that are ordered and avoid time consuming healthcare insurer gatekeepers. The clinical information provided at the time of ordering is combined with the patient age to produce the “utility score” for the exam requested. Possible scores range from 1 (very low utility) to 9 (very high utility). The tool enables referring physicians to enter a patient’s symptoms and qualify the effectiveness of their exam choice through realtime appropriate medical image ordering guidance. With constant feedback from 11,000 radiologists from the New England area, today Radport’s rule set is between 11,000 and 13,000. “Radport is a decision support system that guides appropriate diagnostic image ordering to reduce ordering time by up to 80 percent, manage high-cost utilization and improve patient care through appropriate imaging,” said Keith Dreyer, DO, Ph.D., vice chairman of radiology, MGH, and assistant professor of radiology, Harvard Medical School. “The result is that over-utilization due to physician variability can be considerably reduced.” According to Datamonitor, adoption of “Radport type technologies is still low, but it is definitely growing.” When Appropriateness Criteria is Appropriate An important development in decision support and one that is becoming widely adopted in radiology is appropriateness criteria guidelines for ordering imaging exams. By using standards-based ordering decision support, the tool is designed to help clinicians Payers Push for Decision Support Where the controversy lies in appropriateness criteria approval is twofold. First is the motive insurers are driving the adoption of appropriateness criteria as a means to curb utilization costs of imaging exams. Secondly, the reality is that doctors tend to follow the path of least resistance. http://www.ITNonline.net

Table of Contents Feed for the Digital Edition of Image Technology News - November 2008

Image Technology News - November 2008 Contents RSNA CT Systems Imaging An Image is Worth a Thousand Words Ultrasound Systems MBI Takes on FFDM Trouble in Multi-PACS Paradise When is Appropriateness Criteria Appropriate? RIS/PACS in a Web 2.0 World Digital Mammography Helps Center Continue its Commitment to the Best in Patient-Focused Breast Cancer Cardiovascular Imaging Systems PARCA Extends Expertise to World PACS Market

Image Technology News - November 2008

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